Statement Regarding Contributions

Documents and Forms

Document Name Document Type
Form SSA-783 Statement Regarding Contributions Form and Instruction
SSA-783 Statement Regarding Contributions SSA-783 (revised).pdf Form and Instruction
SSA-783 (current).pdf Current SSA-783 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Statement Regarding Contributions	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 404.736 20 CFR 404.360-.404.366

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-783	Statement Regarding Contributions	SSA-783 (revised).pdf		Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,352	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	2,352	2,352
Annual IC Time Burden (Hours)	2,705	2,705
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-783	SSA-783 (current).pdf	09/26/2025

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