Authorization for SSA to Obtain Account Records From a Financial Institution and Request for Records (Medicare Part D Subsidy)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-4640 Authorization for SSA to Obtain Account Records From a Financial Institution and Request for Records (Medicare) (As completed by the claimant.)	Form	Modified	Available
Form SSA-4640 Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records (Medicare) (As completed by the finanical institution.)	Form	Modified	Available
Supporting Statement SSA-4640 (0960-0729).docx	Supporting Statement A	Uploaded 2012-08-13	Available
Addendum 0960-0729.doc	Supplementary Document	Uploaded 2012-05-22	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
43717	Authorization for SSA to Obtain Account Records From a Financial Institution and Request for Records (Medicare) (As completed by the claimant.)	Form	Modified
189623	Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records (Medicare) (As completed by the finanical institution.)	Form	Modified

ICR Details

OMB Control No: 0960-0729	ICR Reference No: 201204-0960-005
Status: Historical Active	Previous ICR Reference No: 200902-0960-009
Agency/Subagency: SSA	Agency Tracking No:
Title: Authorization for SSA to Obtain Account Records From a Financial Institution and Request for Records (Medicare Part D Subsidy)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/25/2012
	Date Received in OIRA: 08/15/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2015	36 Months From Approved	11/30/2012
Responses	10,000	0	10,000
Time Burden (Hours)	416	0	416
Cost Burden (Dollars)	0	0	0

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Abstract: Individuals who apply for the Medicare Part D subsidy must report all of their financial accounts. In cases where SSA chooses to verify applicants' account balances, we use Form SSA-4640 to: 1) obtain applicants' authorizations to contact their financial institutions and 2) verify balances with the financial institutions. The respondents are applicants for the Medicare Part D subsidy with financial accounts, and the institutions where those accounts are held.

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Authorizing Statute(s): PL: Pub.L. 108 - 173 101 Name of Law: Medicare Prescription Drug Benefit
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 27829	05/11/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 47908	08/10/2012
Did the Agency receive public comments on this ICR? No

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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 (Medicare) (As completed by the claimant.)	SSA-4640	Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records (Medicare) (As completed by the claimant)
Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records (Medicare) (As completed by the finanical institution.)	SSA-4640	Authorization...

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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	10,000	10,000	0	0	0	0
Annual Time Burden (Hours)	416	416	0	0	0	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:

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Annual Cost to Federal Government: $2,200

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

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Common Form ICR:  No

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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: 08/15/2012

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