SSN Policy Manual

Rescind your Social Security Number

PAPERWORK REDUCTION ACT SUBMISSION Please read the instructions before completing this form. For additional forms or assistance in completing this form, contact your agency's Papetwork Clearance Ofticer. Send two copies of this form, the collection instrument to be reviewed, the Supporting Statement, and any additional documentation to: Office of Information and RegulatoryAffairs, Office of Management and Budget, Docket Library, Room 10102, 725 17th Street N.W., Washington, DC 20503 1. AgencyISubagency originating request . OMB control number SOCIAL SECURITY ADMINISTRATION a. 0960 - 0066 b. None 3. Type of information collectiin (check we) . Type of rewew requested (check one)

I

a. rn Regular submission b.

a , 0 New Collection

Emergency-Approvalrequested by:

b . m Revision of a currently approved collection c . O Extension of a currentlyapproved collection

c.

Mesated

d.O Reinstatement, without change, of previously approved

. Small entities

collection for whkh approval has expired

on a substantial number of small entities?

e . n Reinstatement,with change, of a previously approved

collection for hich approval has expired

a. rn Three years from approval date b. Other Specify -.

f . 0 Existing collection in use without an OMB control number For b-f, note ifem A2 d S u p p d n g Statement lnsbuctions

qv K? (rz-.

b

(-'?, T z [j; &, 2, ,; dA

7. Title

, ,i

Application for a Social Security Card

,.),I 1 7 , i , , ', . ?\iS

8. Agency form number(s) (if applicable)

DEC 22 lgg7

-- - SS-5

9. Keywords Social Securitv Benefits. Identification Card

OIRA DOCKET LIBRRK'

The information collected on Form SS-5 is used by the Social Security Administration to assign Social Security Numbers so that individuals may obtain employment, report earnings, open bank accounts. pay taxes, apply for benefits and for other purposes. The affected public consists of individuals who

gpply for Social Security Numbers.

12. Obligation to respond (Mak primary with "P" and all ofhers mar gm "'Ih a. -voluntary Z7 I b. E ~ e q u i r e tdo obtain or retain benefits c. - anda at or^ f 4. Annual reporting and recordkeep~ngcost burden (m thousad or &Am a. Total annuallzed capitaustartupm s k NIA b. Total annual cost ( 0 8 M) c. Total annualizedcost requested d. Current OMB invenbry e. Difference f. Explanation of difference 1. Program change 2. Adjustment

I I. Affected public (Mark primary with P" 8 all others that apply with X") a. X Individuals or households d. - Farms b. - Business or other fur-profit e. - Federal Government c. - Not-for-profit institutions f. - State. Local or Tribal Government 13. Annual reporting and recornkeepinghour burden a. Number of respndenk 16,000,000 b. ~ o t a ~ annual responses 16,000,000 1. Percentageof these responses collected elecbonifaliy 0 c. Total annual hours requested 2,275,000 d. Current OMB inventory 2,000,000 e. Differences 2,275,000 f. Explanation of difference 1. Program change 0 2. Adjustmenk +275,000 14. Purpose of information (Mark primarywith "P" and all others that apply with 'X')

I 16. Frequencyof recordkeepingor reporting (check all that mp& '

e. - Program planning or management

a.

Application for benefts

b. - Program evaluation

f.-

Research

g. - Regulatory or compliance

c. - General purpose statistics

I

d. - Audit 17. Statistical methods Does this Informationcollection employ statiskdl methods?

7 . 0 Biennially 9 . 0 Olher (describe) 118. Agency contact (personwho can best answer quesbons

I content of this submission) I Name

h

Frederick W. Brickenkarnp

Yes

NO

OMB FORM 83-1 (10195)