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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-4641-U2 Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records	Form and Instruction	Modified	Available
OMB-4641-change_sheet_FY11FY12.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2011-03-18	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9201	Authorization for SSA to Obtain Account Records From A Financial Institution And Request For Records - SSA-4641-U2	Form and Instruction	Modified	Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records
191430	Authorization for SSA to Obtain Account Records From A Financial Institution And Request for Records - e4641	Other-Electronic Screens	Modified

ICR Details

OMB Control No: 0960-0293	ICR Reference No: 201103-0960-008
Status: Historical Active	Previous ICR Reference No: 200907-0960-010
Agency/Subagency: SSA	Agency Tracking No:
Title: Authorization for SSA to Obtain Account Records From A Financial Institution And Request For Records
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/07/2011
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/16/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2013	04/30/2013	04/30/2013
Responses	3,000,000	0	500,000
Time Burden (Hours)	119,757	0	50,000
Cost Burden (Dollars)	0	0	0

---

Abstract: The SSA-4641-U2 provides financial institutions with the applicant, recipient, or deemer's authorization to disclose records. The collected information helps determine eligibility for SSI benefits and for program evaluation purposes. Financial institutions, who are the respondents to this collection, are not legally required to complete the SSA-4641-U2. However, financial institution employees complete the form on an occasional basis at the request of the agency. The respondents are financial institutions used by SSI applicants, recipients and/or deemers. In this change request, we are increasing the burden to reflect the larger number of respondents we anticipate will use the form.

---

Authorizing Statute(s): US Code: 42 USC 1383 Name of Law: Social Security Act
   US Code: 12 USC 35, sections 3402-3404 Name of Law: Right to Financial Privacy Act of 1978
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 39728	08/07/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 67945	12/21/2009
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Authorization for SSA to Obtain Account Records From A Financial Institution And Request For Records - SSA-4641-U2	SSA-4641-U2	Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records
Authorization for SSA to Obtain Account Records From A Financial Institution And Request for Records - e4641

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	3,000,000	500,000	0	0	2,500,000	0
Annual Time Burden (Hours)	119,757	50,000	0	0	69,757	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The addition of the electronic version of the SSA-4641, the e4641, is a program change. SSA recognizes that our current usage of the e4641 System is in violation of the PRA and we are rectifying that through this ICR. Please note that there has been a decrease in burden hours for the paper version SSA-4641-U2, due to the increase in the electronic version e4641.

---

Annual Cost to Federal Government: $1,657,073

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 03/16/2011

---