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Federal forms, ICRs, and supporting documents

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
Document Name
Document Type
Form and Instruction
Form and Instruction
Other-Electronic Screens
Other-Electronic Screens
Other-Electronic Screens
Other-Electronic Screens
Form and Instruction
Form and Instruction
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Authorization for SSA to Obtain Account Records From A Financial Institution And Request For Records - Individuals (Paper and Electronic)
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 416.200 20 CFR 416.203

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 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
Other-Electronic Screens e4641 Screenshots.pdf Yes Yes Fillable Fileable Signable
Other-Electronic Screens eAFI Screenshots.pdf Yes No Fillable Printable

Income Security General Retirement and Disability

 

1,439,800 0
   
Individuals or Households
 
   0 %

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