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Authorization for SSA to Obtain Account Records From A Financial Institution And Request for Records - Financial Institutions (Paper)

IC 191430 under ICR 202604-0960-001 · OMB 0960-0293.

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Authorization for SSA to Obtain Account Records From A Financial Institution And Request for Records - Financial Institutions (Paper)
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 416.200

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form SSA-4641 Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records SSA-4641 (revised).pdf Yes No Fillable Printable

Income Security General Retirement and Disability

 

158,789 0
   
Private Sector Businesses or other for-profits
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 158,789 0 0 68,789 0 90,000
Annual IC Time Burden (Hours) 15,879 0 0 6,879 0 9,000
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
SSA-4641 - Current SSA-4641 (current).pdf 04/03/2026
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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