Information Collection

Financial Institutions

IC 189623 under ICR 202103-0960-009 · OMB 0960-0729.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0729 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-4640 Financial Institutions	Form
Form SSA-4640 Authorization... Financial Institutions	Form
SSA-4640 Authorization... SSA-4640 - Revised.pdf	Form
SSA-4640 Authorization... SSA-4640 - Revised.pdf	Form
SSA-4640 - Current.pdf SSA-4640 - Current	IC Document
SSA-4640 - Current.pdf SSA-4640 - Current	IC Document

IC Title:

Financial Institutions

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 418.3420

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	SSA-4640				No		Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	5,000	0	5,000
Annual IC Time Burden (Hours)	833	500	333
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-4640 - Current		07/26/2021

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

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