Information Collection

Certificate of Incapacity

IC 44832 under ICR 200608-0960-010 · OMB 0960-0739.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0739 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-604 Certificate of Incapacity Form and Instruction
SSA-604 Certificate of Incapacity New SSA-604.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Certificate of Incapacity	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 5 CFR 890.302(d)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-604	Certificate of Incapacity	New SSA-604.pdf		No		Paper Only

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 38	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	38	38
Annual IC Time Burden (Hours)	29	29
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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