Information Collection

Authorization for SSA to Obtain Account Records From A Financial Institution And Request For Records - Individuals (Paper and Electronic)

IC 9201 under ICR 202604-0960-001 · OMB 0960-0293.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-4641 Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records Authorization for SSA to Obtain Account Records From A Financial Institution And Request For Records - Individuals (Paper and Electronic)	Form and Instruction
Form SSA-4641 Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records Authorization for SSA to Obtain Account Records From A Financial Institution And Request For Records - Individuals (Paper and Electronic)	Form and Instruction
e4641 Screenshots.pdf	Other-Electronic Screens
e4641 Screenshots.pdf	Other-Electronic Screens
eAFI Screenshots.pdf	Other-Electronic Screens
eAFI Screenshots.pdf	Other-Electronic Screens
SSA-4641 Authorization for the Social Security Administration to SSA-4641 (revised).pdf	Form and Instruction
SSA-4641 Authorization for the Social Security Administration to SSA-4641 (revised).pdf	Form and Instruction
SSA-4641 (current).pdf SSA-4641 - Current	IC Document
SSA-4641 (current).pdf SSA-4641 - Current	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 416.200 20 CFR 416.203

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-4641	Yes	No	Fillable Printable
Other-Electronic Screens		Yes	Yes	Fillable Fileable Signable
Other-Electronic Screens		Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,439,800

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	1,439,800	-125,200	1,565,000
Annual IC Time Burden (Hours)	647,910	-238,923	886,833
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-4641 - Current		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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