Information Collection

0960-0300 HA-4633 (Paper Form) 410.1560; 404.1565; 416.960; 416.965

IC 262362 under ICR 202309-0960-005 · OMB 0960-0834.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0834 can be found here:

Documents and Forms

Document Name Document Type
Form HA-4633 0960-0300 HA-4633 (Paper Form) 410.1560; 404.1565; 416.960; 416.965 Form and Instruction
HA-4633 Claimant's Work Background HA-4633 (Revised for PRW NPRM).pdf www.ssa.gov Form and Instruction
HA-4633 Claimant's Work Background HA-4633 (Revised for PRW NPRM).pdf www.ssa.gov Form and Instruction
HA-4633 (Current).pdf Current HA-4633 IC Document
HA-4633 (Current).pdf Current HA-4633 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	0960-0300 HA-4633 (Paper Form) 410.1560; 404.1565; 416.960; 416.965	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 404.1565 20 CFR 416.960 20 CFR 410.1560 20 CFR 416.965

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	HA-4633	Claimant's Work Background	HA-4633 (Revised for PRW NPRM).pdf	www.ssa.gov	No		Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 32,300	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	32,300	32,300
Annual IC Time Burden (Hours)	10,767	10,767
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Current HA-4633	HA-4633 (Current).pdf	10/02/2023

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