Authorization for SSA to Obtain Account Records From A Financial Institution And Request for Records - e4641 and AFI System

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0293 can be found here:

Documents and Forms

Document Name Document Type
e4641 Screens - Revised.pdf Other-Electronic Screens
AFI Screenshots.pdf Other-AFI screens
e4641 Screens - Current.pdf e4641 Screens - Current IC Document

Information Collection (IC) Details

IC Title:	Authorization for SSA to Obtain Account Records From A Financial Institution And Request for Records - e4641 and AFI System	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 416.200

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Electronic Screens			e4641 Screens - Revised.pdf		Yes	Yes	Fillable Fileable Signable
Other-AFI screens			AFI Screenshots.pdf		No		Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 15,860,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	15,860,000	112,500	15,747,500
Annual IC Time Burden (Hours)	528,667	3,750	524,917
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
e4641 Screens - Current	e4641 Screens - Current.pdf	12/12/2018

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