Statement of Self-Employment Income

Documents and Forms

Document Name Document Type
Form SSA-766 Statement of Self-Employment Income Form
PA Statement 0046 (revised).docx Other-Revised Privacy Act Statement
PRA 0046 (revised).docx Other-Paperwork Reduction Act (revis
SSA-766 Statement of Self-Employment Income SSA-766.(revised).pdf www.ssa.gov Form
SSA-766 (current).pdf SSA-766 Current Version IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Statement of Self-Employment Income	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.610 20 CFR 404.110 20 CFR 404.1096 20 CFR 404.611 20 CFR 404.101 20 CFR 422.405

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Electronic Capability
Form	SSA-766	Statement of Self-Employment Income	SSA-766.(revised).pdf	www.ssa.gov	No	Fillable Printable
Other-Revised Privacy Act Statement			PA Statement 0046 (revised).docx		No	Printable Only
Other-Paperwork Reduction Act (revised)			PRA 0046 (revised).docx		No	Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 910	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	910	-1,590	2,500
Annual IC Time Burden (Hours)	76	-132	208
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-766 Current Version	SSA-766 (current).pdf	09/30/2021

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.