Information Collection

Authorization for SSA to Obtain Account Records From A Financial Institution And Request for Records - Financial Institutions (Paper)

IC 191430 under ICR 202201-0960-009 · OMB 0960-0293.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0293 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-4641 Authorization for SSA to Obtain Account Records From A Financial Institution And Request for Records - Financial Institutions (Paper)	Form
Revised PA & PRA Statements.pdf	Other-Revised PA & PRA Statements
SSA-4641 Authorization for the Social Security Administration to SSA-4641 - Revised.pdf	Form
SSA-4641 - Current.pdf SSA-4641 - Current	IC Document

IC Title:

Authorization for SSA to Obtain Account Records From A Financial Institution And Request for Records - Financial Institutions (Paper)

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 416.200

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-4641	Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records	SSA-4641 - Revised.pdf		Yes	No	Fillable Printable
Other-Revised PA & 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: 90,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	90,000	-15,770,000	15,860,000
Annual IC Time Burden (Hours)	9,000	-519,667	528,667
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-4641 - Current	SSA-4641 - Current.pdf	05/18/2022

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