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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
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	Modified	Available
Addendum - 0293.docx	Supplementary Document	Uploaded 2019-01-29	Available
Supporting Statement - 0293.docx	Supporting Statement A	Uploaded 2019-01-29	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9201	Authorization for SSA to Obtain Account Records From A Financial Institution And Request For Records - SSA-4641-U2	Form and Instruction	Modified
191430	Authorization for SSA to Obtain Account Records From A Financial Institution And Request for Records - e4641 and AFI System	Other-Electronic Screens	Modified

ICR Details

OMB Control No: 0960-0293	ICR Reference No: 201810-0960-017
Status: Active	Previous ICR Reference No: 201602-0960-001
Agency/Subagency: SSA	Agency Tracking No:
Title: Authorization for SSA to Obtain Account Records From A Financial Institution And Request For Records
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: 06/25/2019
	Date Received in OIRA: 02/04/2019
Terms of Clearance: In accordance with 5 CFR 1320, the information collection is approved for three years.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2022	36 Months From Approved	06/30/2019
Responses	16,000,000	0	16,000,000
Time Burden (Hours)	542,667	0	550,167
Cost Burden (Dollars)	0	0	0

---

Abstract: SSA collects and verifies financial account information from individuals requesting a waiver of their Title II and Title XVI overpayments, as well as those who apply for, or currently receive (in the case of redetermination) Supplemental Security Income (SSI) payments. We require financial information from these individual’s to: (1) determine the eligibility of the applicant or recipient for SSI benefits; or (2) determine if a request to waive a Social Security overpayment defeats the purpose of the Act. If an individual provides incomplete or seemingly altered records, or if records are unavailable, SSA contacts his or her financial institutions to verify the existence; ownership; and value of accounts owned. Financial institutions need individuals to sign Form SSA-4641-F4, or contact SSA and use the Internet version, e4641, to authorize them to disclose the individual’s records to SSA. The respondents are Title II and Title XVI recipients applying for waivers, or SSI applicants, recipients, and their deemors to determine SSI eligibility.

---

Authorizing Statute(s): US Code: 42 USC 1383 Name of Law: Social Security Act
   PL: Pub.L. 114 - 74 834 Name of Law: Bipartisan Budget Act
   US Code: 12 USC 35, sections 3402-3404 Name of Law: Right to Financial Privacy Act of 1978
  

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 56133	11/09/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 371	01/25/2019
Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

IC Title	Form No.	Form Name
Authorization for SSA to Obtain Account Records From A Financial Institution And Request For Records - SSA-4641-U2	SSA-4641-U2	Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records
Authorization for SSA to Obtain Account Records From A Financial Institution And Request for Records - e4641 and AFI System

---

ICR Summary of Burden

table that charts list 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	16,000,000	16,000,000	0	0	0	0
Annual Time Burden (Hours)	542,667	550,167	0	0	-7,500	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: When we last cleared this IC in 2015, the burden was 550,167 hours. However, we are currently reporting a burden of 542,667 hours. This change stems from a decrease in the number of responses for the SSA-4641 from 252,500 to 140,000, and an increase in the number of responses for the e4641 from 15,747,500 to 15,860,000. There is no change to the burden time per response. Although the number of responses changed, SSA did not take any actions to cause this change.

---

Annual Cost to Federal Government: $13,800,013

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: 02/04/2019

---