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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.