Information Collection

Authorization for SSA to Obtain Account Records From A Financial Institution And Request for Records - e4641

IC 191430 under ICR 200907-0960-010 · OMB 0960-0293.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0293 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
e4641 Screen Shots.pdf	Other-Electronic Screens

IC Title:

Authorization for SSA to Obtain Account Records From A Financial Institution And Request for Records - e4641

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 416.200

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
Other-Electronic Screens			e4641 Screen Shots.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,700

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	180,000	180,000
Annual IC Time Burden (Hours)	18,000	18,000
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.