Authorization for SSA to Obtain Account Records From a Financial Institution and Request for Records (Medicare Part D Subsidy)

Forms and Documents

Document	Type	Status	Availability
Form SSA-4640 Medicare Part D Subsidy Applicants or Claimants	Form	Modified	Available
Form SSA-4640 Financial Institutions	Form	Modified	Repair queued
Addendum - 0729.docx	Supplementary Document	Uploaded 2018-04-03	Repair queued
Supporting Statement - 0729.docx	Supporting Statement A	Uploaded 2018-06-12	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
43717	Medicare Part D Subsidy Applicants or Claimants	Form	Modified
189623	Financial Institutions	Form	Modified

ICR Details

OMB Control No: 0960-0729	ICR Reference No: 201802-0960-005
Status: Active	Previous ICR Reference No: 201502-0960-008
Agency/Subagency: SSA	Agency Tracking No:
Title: Authorization for SSA to Obtain Account Records From a Financial Institution and Request for Records (Medicare Part D Subsidy)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/18/2018
	Date Received in OIRA: 07/04/2018
Terms of Clearance: In accordance with 5 CFR 1320, the information collection is approved for three years.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2021	36 Months From Approved	10/31/2018
Responses	10,000	0	10,000
Time Burden (Hours)	416	0	416
Cost Burden (Dollars)	0	0	0

---

Abstract: Individuals who apply for the Medicare Part D subsidy must report all of their financial accounts. In cases where SSA chooses to verify applicants' account balances, we use Form SSA-4640 to: (1) obtain applicants' authorizations to contact their financial institutions and (2) verify balances with the financial institutions. The respondents are applicants for the Medicare Part D subsidy with financial accounts, and the institutions where those accounts are held.

---

Authorizing Statute(s): PL: Pub.L. 108 - 173 101 Name of Law: Medicare Prescription Drug Benefit
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 12455	03/21/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 26736	06/08/2018
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Medicare Part D Subsidy Applicants or Claimants	SSA-4640	Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records (Medicare) (As completed by the claimant)
Financial Institutions	SSA-4640	Authorization...

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	10,000	10,000	0	0	0	0
Annual Time Burden (Hours)	416	416	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $5,800

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 07/04/2018

---