Information Collection

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

IC 9201 under ICR 201602-0960-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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.pdf	Form and Instruction

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.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: 252,500

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	252,500	151,700	100,800
Annual IC Time Burden (Hours)	25,250	15,170	10,080
Annual IC Cost Burden (Dollars)	0	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.