Financial Institutions

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

OMB: 0960-0729

IC ID: 189623

Information Collection (IC) Details

View Information Collection (IC)

Financial Institutions
 
No Modified
 
Voluntary
 
20 CFR 418.3420

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

Income Security General Retirement and Disability

 

5,000 0
   
Private Sector Businesses or other for-profits
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 5,000 0 0 0 0 5,000
Annual IC Time Burden (Hours) 333 0 0 0 0 333
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.

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