Information Collection

Ha-4633

IC 9205 under ICR 201702-0960-004 · OMB 0960-0300.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0300 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form HA-4633 HA-4633	Form
Revised PA Statement.pdf	Other-Revised PA Statement
HA-4633 Claimant's Work Background HA-4633 - Revised.pdf	Form
HA-4633 - Current.pdf HA-4633 - Current	IC Document

IC Title:

HA-4633

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 404.1512(a) 20 CFR 404.1520(a)(4) 20 CFR 404.1565(b) 20 CFR 416.912(a) 20 CFR 416.920(a)(4) 20 CFR 416.965(b)

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	HA-4633	Claimant's Work Background	HA-4633 - Revised.pdf		No		Printable Only
Other-Revised PA Statement			Revised PA Statement.pdf		No		Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	200,000	200,000
Annual IC Time Burden (Hours)	50,000	50,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
HA-4633 - Current	HA-4633 - Current.pdf	03/29/2017

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