Information Collection

Medicare Part D Subsidy Applicants or Claimants

IC 43717 under ICR 201502-0960-008 · OMB 0960-0729.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-4640 Medicare Part D Subsidy Applicants or Claimants	Form
SSA-4640 Authorization for the Social Security Administration to SSA-4640.pdf	Form

IC Title:

Medicare Part D Subsidy Applicants or Claimants

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:

table that charts list of 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.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 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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