Information Collection

Financial Disclosure for Civil Monetary Penalty (CMP) Debt

IC 188515 under ICR 202105-0960-002 · OMB 0960-0776.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0776 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-640 Financial Disclosure for Civil Monetary Penalty (CMP) Debt	Form and Instruction
Revised PA & PRA Statements.pdf	Other-Revised PA and PRA Statements
SSA-640 Financial Disclosure for Civil Monetary Penalty (CMP) De SSA-640 - Revised.pdf	Form and Instruction
SSA-640 - Current.pdf SSA-640 - Current	IC Document

IC Title:

Financial Disclosure for Civil Monetary Penalty (CMP) Debt

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 498

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	SSA-640	Financial Disclosure for Civil Monetary Penalty (CMP) Debt	SSA-640 - Revised.pdf		Yes	No	Fillable Printable
Other-Revised PA and PRA Statements			Revised PA & PRA Statements.pdf		Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	10	0	10
Annual IC Time Burden (Hours)	25	5	20
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-640 - Current	SSA-640 - Current.pdf	09/07/2021

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