Information Collection

Certificate of Incapacity

IC 44832 under ICR 201601-0960-004 · OMB 0960-0739.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0739 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-604 Certificate of Incapacity	Form and Instruction
SSA-604 Certificate of Incapacity SSA-604 (Revised Version).pdf	Form and Instruction
SSA-604 (Current Version).pdf Certificate of Incapacity (current verison)	IC Document

IC Title:

Certificate of Incapacity

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 5 CFR 890.302(d)

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-604	Certificate of Incapacity	SSA-604 (Revised Version).pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	38	38
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Certificate of Incapacity (current verison)	SSA-604 (Current Version).pdf	03/16/2016

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