Information Collection

HA-4633 - Paper Version

IC 9205 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 - Paper Version	Form
Form HA-4633 Claimant's Work Background HA-4633 - Paper Version	Form
HA-4633 Claimant's Work Background HA-4633 - Revised Version.pdf	Form
HA-4633 Claimant's Work Background HA-4633 - Revised Version.pdf	Form
HA-4633 (Prior to PRW Rule).pdf HA-4633 - Prior to Implementation of the PRW Rule	IC Document
HA-4633 (Prior to PRW Rule).pdf HA-4633 - Prior to Implementation of the PRW Rule	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 404.1565(b) 20 CFR 416.912(a) 20 CFR 404.1520(a)(4) 20 CFR 416.920(a)(4) 20 CFR 404.1512(a) 20 CFR 416.965(b)

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	HA-4633			www.ssa.gov (mySocial Security Account - Upload Documents)	No		Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 48,450

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	48,450	16,150	32,300
Annual IC Time Burden (Hours)	16,150	0	16,150
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
HA-4633 - Prior to Implementation of the PRW Rule		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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