Medicare Part D Subsidy Applicants or Claimants

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

OMB: 0960-0729

IC ID: 43717

Information Collection (IC) Details

View Information Collection (IC)

Medicare Part D Subsidy Applicants or Claimants
 
No Modified
 
Required to Obtain or Retain Benefits
 
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 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

Income Security General Retirement and Disability

 

5,000 0
   
Individuals or Households
 
   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) 83 0 0 0 0 83
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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

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