Information Collection

Expanded Monitoring Site Review: Beneficiary Interview Form

IC 178591 under ICR 200702-0960-001 · OMB 0960-0633.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0633 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-639 (revised) Expanded Monitoring Site Review: Beneficiary Interview Form Form
SSA-639 (revised) Expanded Monitoring Site Review Beneficiary Review Form SSA-639--Revised.doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Expanded Monitoring Site Review: Beneficiary Interview Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.2065 20 CFR 416.701 20 CFR 416.665 20 CFR 416.708 20 CFR 404.2035

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-639 (revised)	Expanded Monitoring Site Review Beneficiary Review Form	SSA-639--Revised.doc		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,741	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	7,741	7,741
Annual IC Time Burden (Hours)	1,290	1,290
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.