Information Collection

Certificate of Incapacity

IC 44832 under ICR 200907-0960-014 · 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⚠️ Notice: This information collection may be referencing outdated material.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 SSA-604-final draft to author.pdf	Form and Instruction
ssa604.pdf Certificate of Incapacity (current verison)	IC Document

IC Title:

Certificate of Incapacity

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	SSA-604-final draft to author.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	50	12	38
Annual IC Time Burden (Hours)	38	9	29
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Certificate of Incapacity (current verison)	ssa604.pdf	12/10/2009

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