Information Collection

HA-4633 - Electronic Records Express Submissions

IC 243285 under ICR 202508-0960-003 · OMB 0960-0300.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form HA-4633 Claimant’s Work Background HA-4633 - Electronic Records Express Submissions	Form and Instruction
Form HA-4633 Claimant’s Work Background HA-4633 - Electronic Records Express Submissions	Form and Instruction
ERE Screen Package.pdf	Other-Internet Screens
ERE Screen Package.pdf	Other-Internet Screens
HA-4633 Claimant’s Work Background HA-4633 - Revised Version.pdf	Form and Instruction
HA-4633 Claimant’s Work Background HA-4633 - Revised Version.pdf	Form and Instruction
HA-4633 (Prior to PRW Rule).pdf Current HA-4633	IC Document
HA-4633 (Prior to PRW Rule).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 404.1520(a)(4) 20 CFR 404.1512(a) 20 CFR 416.965(b) 20 CFR 404.1565(b) 20 CFR 416.912(a) 20 CFR 416.920(a)(4)

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			www.ssa.gov (mySocial Security Account - Representative Payees)	Yes	Yes	Fillable Fileable Signable
Other-Internet Screens				www.ssa.gov (ERE)	Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 236,550

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	236,550	78,850	157,700
Annual IC Time Burden (Hours)	78,850	0	78,850
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current HA-4633		03/11/2026

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

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].