Financial Disclosure for Civil Monetary Penalty (CMP) Debt

Forms and Documents

Document	Type	Status	Availability
Form SSA-640 Financial Disclosure for Civil Monetary Penalty (CMP) Debt	Form and Instruction	Modified	Available
Form SSA-640 Financial Disclosure for Civil Monetary Penalty (CMP) Debt	Form and Instruction	Modified	Repair queued
Justification for the Non-Substantive Changes - 0960-0776 (Removal of Signature Requirement).docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-04-28	Available
Justification for the Non-Substantive Changes - 0960-0776 (Removal of Signature Requirement).docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-04-28	Missing upstream
Supporting Statement - 0776 (Clean Copy).docx	Supporting Statement A	Uploaded 2023-06-13	Available
Supporting Statement - 0776 (Clean Copy).docx	Supporting Statement A	Uploaded 2023-06-13	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
188515	Financial Disclosure for Civil Monetary Penalty (CMP) Debt	Form and Instruction	Modified	Financial Disclosure for Civil Monetary Penalty (CMP) Debt
188515	Financial Disclosure for Civil Monetary Penalty (CMP) Debt	Form and Instruction	Modified

ICR Details

OMB Control No: 0960-0776	ICR Reference No: 202504-0960-005
Status: Active	Previous ICR Reference No: 202105-0960-002
Agency/Subagency: SSA	Agency Tracking No:
Title: Financial Disclosure for Civil Monetary Penalty (CMP) Debt
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/13/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/29/2025
Terms of Clearance: Approved consistent with the agency's commitments under Sec. 4 (k)(iii) and (iv) of E.O. 14058.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2026	06/30/2026	06/30/2026
Responses	10	0	10
Time Burden (Hours)	25	0	25
Cost Burden (Dollars)	0	0	0

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Abstract: When SSA imposes a civil monetary penalty (CMP) on individuals for various fraudulent conduct related to SSA-administrated programs, those individuals may request to pay the CMP through benefit withholding, or an installment agreement. To negotiate a monthly payment amount, fair to both the individual and the agency, SSA needs financial information from the individual. The agency uses Form SSA-640 to obtain the information necessary to determine a monthly installment repayment rate for individuals owing a CMP. The respondents are recipients of Social Security benefits, and non-entitled individuals who must repay a CMP to the agency and choose to do so using an installment plan. We are submitting a non-substative change request to remove the signature requirement from Form SSA-640.

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Authorizing Statute(s): US Code: 42 USC 1320 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 33007	06/23/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 49403	09/02/2021
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Financial Disclosure for Civil Monetary Penalty (CMP) Debt	SSA-640	Financial Disclosure for Civil Monetary Penalty (CMP) Debt

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	10	10	0	0	0	0
Annual Time Burden (Hours)	25	25	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: There are no changes to the public reporting burden. However, we updated the burden hours in ROCIS to include the 30-minute travel time to a field office, which increased the overall burden for this collection.

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Annual Cost to Federal Government: $4,595

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 04/29/2025

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