Information Collection

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

IC 253711 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⚠️ Notice: This information collection may be referencing outdated material.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
e4641 Screenshots.pdf	Other-Electronic Screens
eAFI Screenshots.pdf	Other-Electronic Screens

IC Title:

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

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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
Other-Electronic Screens			e4641 Screenshots.pdf		Yes	Yes	Fillable Fileable Signable
Other-Electronic Screens			eAFI Screenshots.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: 14,575,000

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
Annual Number of Responses for this IC	14,575,000	14,575,000
Annual IC Time Burden (Hours)	485,833	485,833
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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