Authorization for SSA to Obtain Account Records From a Financial Institution and Request for Records (Medicare) (As completed by the claimant.)

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0729 can be found here:

Documents and Forms

Document Name Document Type
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
SSA-4640 Authorization for the Social Security Administration to SSA-4640 Revised Version.pdf Form
SSA-4640 Current Version.pdf SSA-4640 Current Version IC Document

Information Collection (IC) Details

IC Title:	Authorization for SSA to Obtain Account Records From a Financial Institution and Request for Records (Medicare) (As completed by the claimant.)	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 418.3420

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
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 claimant)	SSA-4640 Revised Version.pdf		No		Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	5,000	5,000
Annual IC Time Burden (Hours)	83	83
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-4640 Current Version	SSA-4640 Current Version.pdf	05/22/2012

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