Information Collection

Authorization for SSA to Obtain Account Records From A Financial Institution And Request For Records - Individuals (Paper and Electronic)

IC 9201 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⚠️ Notice: This information collection may be referencing outdated material.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 - Individuals (Paper and Electronic)	Form and Instruction
Revised PA & PRA Statements.pdf	Other-Revised PA & PRA Statements
e4641 Screenshots.pdf	Other-Electronic Screens
eAFI Screenshots.pdf	Other-Electronic Screens
SSA-4641 Authorization for the Social Security Administration to SSA-4641 - Revised.pdf	Form and Instruction
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 - Individuals (Paper and Electronic)

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 20 CFR 416.203

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	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
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: 1,565,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,565,000	1,425,000	140,000
Annual IC Time Burden (Hours)	886,833	872,833	14,000
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.