Information Collection

Claimant's Work Background

IC 9205 under ICR 201106-0960-009 · OMB 0960-0300.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0300 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form HA-4633 Claimant's Work Background	Form
HA-4633 Claimant's Work Background HA-4633.doc.pdf	Form
HA-4633.pdf Claimant's Work Background (current)	IC Document

IC Title:

Claimant's Work Background

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.965(b) 20 CFR 404.1565

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	HA-4633	Claimant's Work Background	HA-4633.doc.pdf		Yes	No	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	200,000	2,500	46,500	151,000
Annual IC Time Burden (Hours)	50,000	625	11,625	37,750
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Claimant's Work Background (current)	HA-4633.pdf	10/20/2011

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