Information Collection

Claimant's Medications - ERE Internet Version

IC 189495 under ICR 202407-0960-005 · OMB 0960-0289.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Electronic Record Express - Representative Upload Files Instructions (Internet Screens).pdf	Other-Internet Screens
Revised PA Statement - HA-4632.pdf	Other-Revised Privacy Act Statement
HA-4632 Claimant's Medications HA-4632 - Revised Version.pdf	Form
HA-4632 - Current Version.pdf Current HA-4632	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 406.912 20 CFR 404.1512

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-Internet Screens			Electronic Record Express - Representative Upload Files Instructions (Internet Screens).pdf		Yes	Yes	Fillable Fileable Signable
Form	HA-4632	Claimant's Medications	HA-4632 - Revised Version.pdf	www.ssa.gov	Yes	Yes	Fillable Fileable Signable
Other-Revised Privacy Act Statement			Revised PA Statement - HA-4632.pdf		Yes	No	Printable Only

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 249,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	249,000	112,200	136,800
Annual IC Time Burden (Hours)	83,000	48,800	34,200
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current HA-4632	HA-4632 - Current Version.pdf	12/13/2024

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