Information Collection

Expanded Monitoring Site Review: Beneficiary Interview Form

IC 178591 under ICR 201507-0960-011 · OMB 0960-0633.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0633 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-639 Expanded Monitoring Site Review: Beneficiary Interview Form	Form
SSA-639 revised PRA.doc	Other-Paperwork Reduction Act Statem
SSA-639 Expanded Monitoring Site Review Beneficiary Review Form SSA-639 (revised).pdf	Form
ssa639 (current).pdf Current SSA-639	IC Document

IC Title:

Expanded Monitoring Site Review: Beneficiary Interview Form

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 404.2035 20 CFR 416.708 20 CFR 404.2065 20 CFR 416.665 20 CFR 416.701

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-639	Expanded Monitoring Site Review Beneficiary Review Form	SSA-639 (revised).pdf		No		Paper Only
Other-Paperwork Reduction Act Statement Revised			SSA-639 revised PRA.doc		No		Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 8,293

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	8,293	8,293
Annual IC Time Burden (Hours)	1,382	1,382
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-639	ssa639 (current).pdf	09/29/2015

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