Information Collection

Medicare Part D Subsidy Applicants or Claimants

IC 43717 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form SSA-4640 Medicare Part D Subsidy Applicants or Claimants Form
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) Medicare Part D Subsidy Applicants or Claimants Form
SSA-4640 Authorization for the Social Security Administration to SSA-4640 - Revised.pdf Form
SSA-4640 Authorization for the Social Security Administration to SSA-4640 - Revised.pdf Form
SSA-4640 - Current.pdf SSA-4640 - Current IC Document
SSA-4640 - Current.pdf SSA-4640 - Current IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medicare Part D Subsidy Applicants or Claimants	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 418.3420

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
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)	SSA-4640 - Revised.pdf		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: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	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	750	83
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-4640 - Current	SSA-4640 - Current.pdf	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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