Information Collection

0960-0300 HA-4633 (Paper Form) 404.1560; 416.960

IC 262362 under ICR 202404-0960-003 · OMB 0960-0834.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form HA-4633 0960-0300 HA-4633 (Paper Form) 404.1560; 416.960	Form and Instruction
HA-4633 Claimant's Work Background HA-4633 (Revised for PRW FR).pdf	Form and Instruction
HA-4633 Claimant's Work Background HA-4633 (Revised for PRW FR).pdf	Form and Instruction
HA-4633 (Current).pdf Current HA-4633	IC Document
HA-4633 (Current).pdf Current HA-4633	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 404.1560 20 CFR 416.960

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 and Instruction	HA-4633	Claimant's Work Background	HA-4633 (Revised for PRW FR).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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	32,300	32,300
Annual IC Time Burden (Hours)	26,917	26,917
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.