OMB Questions Regarding Revisions to the SSA - Follow-Up

OMB Questions Regarding Revisions to the SSA-4641
1) How will claimants/benes get this form?
Response: This is not a self-help form. Claimants do not complete it and obtain information
on their own. The form is completed by an SSA representative and sent to the financial
institution by SSA and returned directly to SSA. The claims representative who is completing
the initial claim or redeterimination will provide the form for the individual’s signature.
OK
2) Where are the form instructions for the portion of the form benes have to fill out?
Response: Claimants/beneficiaries do not have to complete any portion of the form other
than their signature. Individuals typically sign the form in the presence of a claims
representative (who can provide instruction if necessary) and thus additional instructions are
not viewed as necessary. This form has never contained instructions for the individual since
the claims representative completes all relevant information on page 1 except for the
individual’s signature.
Note: The format used in the revised SSA-4641 is patterned after the SSA-4640 which is
used for the Medicare Part-D program. The SSA-4640 was approved by OMB in August,
2006.
OMB Question: OK, except in cases where the form is mailed to benes, then it would appear
that some kind of instruction should be provided to the bene. What are benes told in these
cases?
SSA Response:
As outlined in the addendum to the supporting statement, the SSA-4641 is being modified
due to legislative and regulatory changes. Those legislative and regulatory changes allow
SSA to obtain a permanent authorization to access financial institution information for SSI
applicants, recipients, and deemors. The Agency is currently collecting permanent
authorizations on all initial claims and MSSICS redeterminations. The SSA-4641 is not used
to collect permanent authorizations. Permanent authorizations are collected as a part of the
initial claim and redetermination process.
The collection of permanent authorizations allows the Agency to move towards an electronic
financial account verification process. Under the electronic process, the primary function of
the SSA-4641 will be to serve as an electronic template that will be sent to a financial
institution. With the electronic verification process, the paper SSA-4641 will only be used in
rare situations where a financial institution requires a wet signature. In those instances, the
paper SSA-4641 will likely be completed in-person with the assistance of a claims
representative. If a paper SSA-4641 would need to be mailed to an applicant, recipient, or
deemor, a note would be attached informing the individual to read page one of the document
and to sign where indicated.

a. Where are benes supposed to turn this form in?
Response: The claims representative takes the form after the individual has signed it and
forwards it directly to the financial institution. In cases where the form is mailed to the
individual to obtain their signature, a pre-addressed return envelope is provided to the
individual to return it to SSA.
OMB Question: OK, except in cases where the form is mailed to benes, then it would appear
that some kind of instruction should be provided to the bene. What are benes told in these
cases? Are they just told to “sign here?” Since the bene is authorizing the disclosure of

financial information, there should be some kind of letter explaining what the bene is actually
agreeing to by signing the form.
SSA Response:
See response above.
Note: The Agency has used the existing SSA-4641 for many years. During that time, we
have never received any feedback from the public or our field offices indicating that
individuals were confused or had difficulty understanding or completing the form. Moreover,
under the electronic process, the SSA-4641 will rarely be used in paper form and thus an
emphasis was made to revise the form to make it more conducive to the electronic process.
FYI, under the electronic process, “Permission on File” will be inserted into the customer’s
authorization block. Section 213 of the Foster Care Independence Act of 1999 (P.L. 106169), allows SSA to request financial account information without furnishing the financial
institution with a written authorization.

b. How are they supposed to get the SSA rep’s signature at the bottom of the form?
Do they mail in the form first and then have the SSA rep sign off on it? Or are they
supposed to bring this form into the SSA office? It’s not clear.
Response: The form is typically completed in the SSA field office by SSA personnel and the
claims representative will sign the form after the individual has provided their signature. If the
form is returned by mail in the envelope provided by the field office after the claimant signs
the form, the SSA representative will then sign the form after he/she receives it and forward it
to the financial institution.
OK

c.

Do claimants need to fill out a form for every financial institution they do
business with? This should be made clear
Response: If forms are needed for more than one financial institution, the claims
representative will prepare the forms for the individual’s signature.

OMB Response: OK, but then the wording on the form should be changed (see attached).
SSA Response: We agree with the suggested change.