Information Collection

Financial Disclosure for Civil Monetary Penalty (CMP) Debt

IC 188515 under ICR 201803-0960-011 · OMB 0960-0776.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0776 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-640 Financial Disclosure for Civil Monetary Penalty (CMP) Debt	Form and Instruction
Revised Privacy Act Stateemnt 0776.doc	Other-Privacy Act Statement
SSA-640 Financial Disclosure for Civil Monetary Penalty (CMP) De SSA-640 (revised).pdf	Form and Instruction
ssa-640.pdf Current SSA-640	IC Document

IC Title:

Financial Disclosure for Civil Monetary Penalty (CMP) Debt

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 498

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-640	Financial Disclosure for Civil Monetary Penalty (CMP) Debt	SSA-640 (revised).pdf		No		Paper Only
Other-Privacy Act Statement			Revised Privacy Act Stateemnt 0776.doc		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	10	-390	400
Annual IC Time Burden (Hours)	20	-780	800
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-640	ssa-640.pdf	05/16/2018

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