Information Collection

Authorization for SSA to Obtain Account Records From A Financial Institution And Request For Records - SSA-4641-U2

IC 9201 under ICR 201512-0960-008 · OMB 0960-0293.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0293 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-4641-U2 Authorization for SSA to Obtain Account Records From A Financial Institution And Request For Records - SSA-4641-U2	Form and Instruction
SSA-4641-U2 Authorization for the Social Security Administration to SSA-4641 - Revised Version.pdf	Form and Instruction
SSA-4641 - Current Version.pdf Current SSA-4641-U2	IC Document

IC Title:

Authorization for SSA to Obtain Account Records From A Financial Institution And Request For Records - SSA-4641-U2

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 416.200 20 CFR 416.203

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 and Instruction	SSA-4641-U2	Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records	SSA-4641 - Revised Version.pdf		Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100,800

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	100,800	100,800
Annual IC Time Burden (Hours)	10,080	10,080
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-4641-U2	SSA-4641 - Current Version.pdf	12/29/2015

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