This information collection meets the requirements of 44  U.S.C.  ยง 3507, as amended by section 2 of the Paperwork Reduction Act of 1995.  You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number.

The OMB control number is OMB 0960-0818. The expiration date is 04/19/2022.

We estimate that it will take about 5 minutes to read the instructions, gather the facts, and answer the questions.

You may send comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing this burden to:

Social Security Administration
6401 Security Blvd.
Baltimore, MD 21235-6401

Send only comments on our time estimate to this address, not the completed form.