Information Collection

HA-4633 - Paper Version

IC 9205 under ICR 202007-0960-003 · OMB 0960-0300.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0300 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form HA-4633 HA-4633 - Paper Version	Form
Form HA-4633 Claimant's Work Background HA-4633 - Paper Version	Form
Revised PA and PRA Statements - HA-4633.pdf	Other-Revised PA and PRA Statements
Revised PA and PRA Statements - HA-4633.pdf	Other-Revised PA and PRA Statements
HA-4633 Claimant's Work Background HA-4633 - Revised Version.pdf	Form
HA-4633 Claimant's Work Background HA-4633 - Revised Version.pdf	Form
HA-4633 - Current Version.pdf HA-4633 - Current	IC Document
HA-4633 - Current Version.pdf HA-4633 - Current	IC Document

IC Title:

HA-4633 - Paper Version

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 404.1512(a) 20 CFR 404.1520(a)(4) 20 CFR 404.1565(b) 20 CFR 416.912(a) 20 CFR 416.920(a)(4) 20 CFR 416.965(b)

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	HA-4633				No		Printable Only
Other-Revised PA and PRA Statements					No		Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 32,300

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	32,300	-167,700	200,000
Annual IC Time Burden (Hours)	16,150	-33,850	50,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
HA-4633 - Current		08/21/2020

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

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