Supporting Statement - 0293

Supporting Statement for Form SSA‑4641‑F4

Authorization for the Social Security Administration to Obtain

Account Records from a Financial Institution

20 CFR 416.200, 416.203, 404.508, and 416.553

OMB No. 0960-0293

A. Justification

1. Introduction/Authoring Laws and Regulations

Sections 1631(e)(1)(B) of the Social Security Act (Act), and 20 CFR 416.200 and

416.203 of the Code of Federal Regulations (Code) authorize the Social Security Administration (SSA) to collect and verify information on applications for the Supplemental Security Income (SSI) program. Sections 204(b) and 1631(b)(1)(B) of the Act require SSA to obtain an individual’s authorization to obtain certain financial records before waiving overpayment recovery under the “defeats the purpose” provisions described in 20 CFR 404.508 and 416.553 of the Code. Form SSA‑4641‑F4 complies with the authorization and certification requirements of the Right to Financial Privacy Act of 1978 (12 USC 35 of the United States Code, Sections 3402-3404), which specifies conditions which we must meet before SSA can disclose the account records of financial institutions with customer authorization.

2. Description of Collection

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 individuals provide incomplete or seemingly altered records, or if records are unavailable, SSA contacts their 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.

2. Use of Information Technology to Collect the Information

In accordance with the agency’s Government Paperwork Elimination Act plan, SSA created an Internet version of Form SSA-4641-F4, the e4641. Based on our data, we estimate approximately 99% of respondents under this OMB number use the electronic version of the application. SSA also uses an electronic-based financial account verification system for institutions that require a wet signature to release financial account information. Our Access to Financial Institutions (AFI) System includes screens that allow us to electronically record information, and print out the documentation for signature for cases where we cannot use verbal attestation in place of a wet signature. For those financial institutions that do not have the capability to respond electronically, SSA uses the paper form SSA‑4641-F4.

2. Why We Cannot Use Duplicate Information

The nature of the information we collect and the manner in which we collect it precludes duplication. SSA does not use another collection instrument to obtain similar data.

5. Minimizing Burden on Small Respondents

This collection does not significantly affect small businesses or other small entities.

6. Consequence of Not Collecting Information or Collecting it Less Frequently

If we did not use Form SSA-4641-F4, or the Internet e4641, individuals who are unable to secure necessary evidence on their own (due to physical, mental, or financial limitations) could be disadvantaged, and it would create a high risk of incorrect eligibility determinations and incorrect payment of benefits. Because we collect this information on an as needed basis, we cannot collect it less frequently. There are no technical or legal obstacles to burden reduction.

7. Special Circumstances

There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.

8. Solicitation of Public Comment and Other Consultations with the Public

The 60-day advance Federal Register Notice published on November 9, 2018, at

83 FR 56133, and we received no public comments. The 30-day FRN published on January 25, 2019 at 84 FR 371. If we receive any comments in response to this Notice, we will forward them to OMB.

8. Payment or Gifts to Respondents

We provide payments to the respondents who are financial institutions, to compensate them for the time it takes to respond to our request. SSA pays the respondents at a rate determined by the Federal Reserve Board, in accordance with the Right to Financial Privacy Act of 1978.

8. Assurances of Confidentiality

SSA protects and holds confidential the information it collects in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974), and OMB Circular No. A-130.

8. Justification for Sensitive Questions

The information collection does not contain any questions of a sensitive nature.

8. Estimates of Public Reporting Burden

Modality of Completion	Number of Respondents	Frequency of Response	Average Burden Per Response (minutes)	Estimated Total Annual Burden (hours)
SSA-4641 (Paper)	140,000	1	6	14,000
e4641 & AFI (Internet)	15,860,000	1	2	528,667
Totals	16,000,000			542,667

The total burden for this ICR is 542,667 hours. We based these figures on current management information data. We did not calculate a separate cost burden.

13. Annual Cost to the Respondents (Other)

This collection does not impose a known cost burden on the respondents.

14. Annual Cost To Federal Government

The annual cost to the Federal Government is approximately $13,800,013. This estimate accounts for costs from the following areas: (1) designing, printing, and distributing the form; (2) SSA employee (e.g., field office, 800 number, DDS staff) information collection and processing time; and (3) systems development, updating, and maintenance costs.

15. Program Changes or Adjustments to the Information Collection Request

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.

16. Plans for Publication Information Collection Results

SSA will not publish the results of the information collection.

17. Displaying the OMB Approval Expiration Date

For the paper Form SSA-4641: OMB granted SSA an exemption from the requirement to print the OMB expiration date on its program forms. SSA produces millions of public-use forms with life cycles exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis), OMB granted this exemption so SSA would not have to destroy stocks of otherwise useable forms with expired OMB approval dates, avoiding Government waste.

For the e4641, and AFI System: SSA is not requesting an exception to the requirement to display an expiration date.

18. Exceptions to Certification Statement

SSA is not requesting an exception to the certification requirements at 5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b)(3).

B. Collections of Information Employing Statistical Methods

SSA does not use statistical methods for this information collection.