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 SSA to Obtain Account Records From A Financial Institution And Request For Records - SSA-4641-U2	Form and Instruction	Modified	Available
Supporting Statement 0293 (revised).doc	Supporting Statement A	Uploaded 2012-12-27	Available
Addendum - 0293.doc	Supplementary Document	Uploaded 2012-11-01	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
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: 201209-0960-012
Status: Historical Active	Previous ICR Reference No: 201112-0960-006
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: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/04/2013
	Date Received in OIRA: 01/03/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/29/2016	36 Months From Approved	04/30/2013
Responses	7,000,000	0	5,000,000
Time Burden (Hours)	236,273	0	160,491
Cost Burden (Dollars)	0	0	0

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Abstract: SSA collects and verifies financial information from individuals applying for SSI to determine if the applicant meets the SSI resources eligibility requirements. If the SSI claimants provide records that are incomplete, unavailable, or seemingly altered, SSA contacts their financial institution to verify the existence, ownership, and value of accounts owned. Financial institutions require individuals to sign Form SSA-4641-U2 to authorize them to disclose records to SSA. The respondents are financial institutions of SSI applicants, recipients, and their deemors.

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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

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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 62593	10/15/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 76160	12/26/2012
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 - 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

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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	7,000,000	5,000,000	0	12,524	1,987,476	0
Annual Time Burden (Hours)	236,273	160,491	0	1,252	74,530	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: There has been an increase in the burden hours. The increase stems from our continuing effort to fully implement the Access to Financial Institutions (AFI) initiative. All 50 states, the District of Columbia, and the Northern Mariana Islands are now using AFI, which increase the number of transactions resulting change in an increase in burden hours.

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Annual Cost to Federal Government: $5,161,006

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: 01/03/2013

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