Information Collection

Financial Disclosure Statement

IC 33919 under ICR 202011-3220-004 · OMB 3220-0127.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0127 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DR-423 (04-17) Financial Disclosure Statement	Form and Instruction
DR-423 (04-17) Financial Disclosure Statement Form DR-423 (04-17).pdf	Form and Instruction
DR-423 (04-17) Financial Disclosure Statement Form DR-423 (04-17).pdf	Form and Instruction
Form RL-423 (09-05).pdf Request DR-423 For Waiver of Overpayment	IC Document
Form RL-423 (09-05).pdf Request DR-423 For Waiver of Overpayment	IC Document
SSA-632BK (08-2019).pdf Request for Waiver of Overpayment Recovery	IC Document
SSA-632BK (08-2019).pdf Request for Waiver of Overpayment Recovery	IC Document

IC Title:

Financial Disclosure Statement

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 255 20 CFR 340

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 and Instruction	DR-423 (04-17)	Financial Disclosure Statement	Form DR-423 (04-17).pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: RRB-22, Railroad Retirement, Survivor, and Pensioner Benefit System

FR Citation: 79 FR 58874

Number of Respondents: 1,200

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	Previously Approved
Annual Number of Responses for this IC	1,200	1,200
Annual IC Time Burden (Hours)	1,700	1,700
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Request DR-423 For Waiver of Overpayment	Form RL-423 (09-05).pdf	06/17/2014
Request for Waiver of Overpayment Recovery	SSA-632BK (08-2019).pdf	11/23/2020

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