Information Collection

Financial Disclosure for Civil Monetary Penalty (CMP) Debt - SSA-640

IC 188515 under ICR 202606-0960-003 · OMB 0960-0776.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-640 Financial Disclosure for Civil Monetary Penalty (CMP) Debt Financial Disclosure for Civil Monetary Penalty (CMP) Debt - SSA-640	Form and Instruction
Privacy Act Statement (revised).docx	Other-Privacy Act Statement (revised
SSA-640 Financial Disclosure for Civil Monetary Penalty (CMP) De SSA-640.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 498

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 and Instruction	SSA-640				Yes	No	Fillable Printable
Other-Privacy Act Statement (revised)					No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	10	0	10
Annual IC Time Burden (Hours)	30	5	25
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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

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