Information Collection

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

IC 191430 under ICR 201810-0960-017 · OMB 0960-0293.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.