Information Collection

Claimant's Medication - PDF/Paper Version

IC 43700 under ICR 201502-0960-004 · OMB 0960-0289.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0289 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form HA-4632 Claimant's Medication - PDF/Paper Version	Form
HA-4632 - Revised PA Statement.pdf	Other-Revised Privacy Act Statement
HA-4632 Claimant's Medications HA-4632 - Revised Version.pdf	Form
HA-4632 - Current Version.pdf Current HA-4632	IC Document

IC Title:

Claimant's Medication - PDF/Paper Version

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 404.1512 20 CFR 416.912

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-4632	Claimant's Medications	HA-4632 - Revised Version.pdf		Yes	No	Fillable Printable
Other-Revised Privacy Act Statement			HA-4632 - Revised PA Statement.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: 20,000

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	Previously Approved
Annual Number of Responses for this IC	20,000	20,000
Annual IC Time Burden (Hours)	5,000	5,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current HA-4632	HA-4632 - Current Version.pdf	03/16/2015

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