Information Collection

HA-4633 - Electronic Records Express Submissions

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

Documents and Forms

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 www.ssa.gov (ERE) Other-Internet Screens
ERE Screen Package.pdf www.ssa.gov (ERE) Other-Internet Screens
HA-4633 Claimant’s Work Background HA-4633 - Revised Version.pdf www.ssa.gov (mySocial Security Account - Representative Payees) Form and Instruction
HA-4633 Claimant’s Work Background HA-4633 - Revised Version.pdf www.ssa.gov (mySocial Security Account - Representative Payees) 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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	HA-4633 - Electronic Records Express Submissions	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	HA-4633	Claimantâs Work Background	HA-4633 - Revised Version.pdf	www.ssa.gov (mySocial Security Account - Representative Payees)	Yes	Yes	Fillable Fileable Signable
Other-Internet Screens			ERE Screen Package.pdf	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 %

	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

Title	Document	Date Uploaded
Current HA-4633	HA-4633 (Prior to PRW Rule).pdf	03/11/2026

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

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