Information Collection

Medicare Part D Subsidy Applicants or Claimants

IC 43717 under ICR 202606-0960-005 · OMB 0960-0729.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-4640 Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records (Medicare) (As completed by the claimant) Medicare Part D Subsidy Applicants or Claimants	Form
Privacy Act Statement - Revised.docx	Other-Revised PA Statement
SSA-4640 Authorization for the Social Security Administration to SSA-4640 - Revised.pdf	Form
SSA-4640 - Current.pdf SSA-4640 - 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 418.3420

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	SSA-4640				No		Printable Only
Other-Revised PA Statement					No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,000

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	Previously Approved
Annual Number of Responses for this IC	5,000	5,000
Annual IC Time Burden (Hours)	833	833
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-4640 - Current		06/08/2026

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

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].