Information Collection

Expanded Monitoring Site Review: Beneficiary Interview Form

IC 178591 under ICR 201808-0960-001 · OMB 0960-0633.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0633 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-639 Expanded Monitoring Site Review: Beneficiary Interview Form	Form
Revised PA Statement.pdf	Other-Revised PA Statement
SSA-639 Expanded Monitoring Site Review Beneficiary Review Form SSA-639 - Revised.pdf	Form
SSA-639 - Current.pdf Current SSA-639	IC Document

IC Title:

Expanded Monitoring Site Review: Beneficiary Interview Form

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 404.2035 20 CFR 416.708 20 CFR 404.2065 20 CFR 416.665 20 CFR 416.701

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	SSA-639	Expanded Monitoring Site Review Beneficiary Review Form	SSA-639 - Revised.pdf		No		Fillable Printable
Other-Revised PA Statement			Revised PA Statement.pdf		No		Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 21,772

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	21,772	13,479	8,293
Annual IC Time Burden (Hours)	3,629	2,247	1,382
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-639	SSA-639 - Current.pdf	10/17/2018

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