Information Collection

Expanded Monitoring Site Review: Beneficiary Interview Form

IC 178591 under ICR 202108-0960-001 · OMB 0960-0633.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-639 Expanded Monitoring Site Review: Beneficiary Interview Form	Form
Form SSA-639 Expanded Monitoring Site Review Beneficiary Review Form Expanded Monitoring Site Review: Beneficiary Interview Form	Form
SSA-639 - Revised PA & PRA Statements.pdf	Other-Revised PA & PRA Statements
SSA-639 - Revised PA & PRA Statements.pdf	Other-Revised PA & PRA Statements
SSA-639 Expanded Monitoring Site Review Beneficiary Review Form SSA-639 - Revised.pdf	Form
SSA-639 Expanded Monitoring Site Review Beneficiary Review Form SSA-639 - Revised.pdf	Form
SSA-639 - Current.pdf SSA-639 - Current	IC Document
SSA-639 - Current.pdf SSA-639 - Current	IC Document

IC Title:

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 404.2035 20 CFR 416.708 20 CFR 404.2065 20 CFR 416.665 20 CFR 416.701

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-639				Yes	Yes	Fillable Printable
Other-Revised PA & PRA Statements					Yes	Yes	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 22,000

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	22,000	228	21,772
Annual IC Time Burden (Hours)	3,667	38	3,629
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-639 - Current		01/11/2022

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

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