Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records (Medicare) (As completed by the claimant)
Authorization for SSA to Obtain Account Records From a Financial Institution and Request for Records (Medicare Part D Subsidy)
Revision of a currently approved collection
No
Regular
Approved with change
06/14/2023
08/24/2021
The agency made minor modifications to the supporting statement to clarify the operation of the collection and to increase the burden estimate. Prior to reapproval, the agency will brief OMB on opportunities to use Access to Financial Institutions (AFI) to facilitate this information collection.
table that charts list comparision
Inventory as of this Action
Requested
Previously Approved
06/30/2026
36 Months From Approved
06/30/2023
10,000
0
10,000
1,666
0
416
0
0
0
To determine if subsidy applicants or recipients qualify, or continue to qualify, for the subsidy, SSA conducts quality reviews of selected applications under the Medicare Quality Review System (OMB No. 0960-0707). As part of the quality review, SSA verifies claimantsâ reported financial accounts as discussed in section 20 CFR 418.3420 of the Code of Federal Regulations. To complete this verification, SSA needs to obtain authorization from claimants to contact their financial institutions (FI) to verify the reported account balances. SSA uses Form SSA-4640 to: (1) obtain the individualâs consent to verify balances of FI accounts; and (2) obtain verification of such balances from the FI. The respondents are subsidy applicants or claimants and their FI.
When we last cleared this IC in 2018, the burden was 416 hours. However, we are currently reporting a burden of 1,666 hours. This change stems from an increase in the completion time from 1 and 4 minutes to 10 minutes. After review, we determined the form takes longer than previously reported, which is reflected in the increase in completion time and the resulting change in burden. These figures represent current Management Information data.
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Form SSA-4640 Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records (Medicare) (As completed by the claimant)
Addendum - 0729 (Final).docx
Medicare Part D Subsidy Applicants or Claimants