OMB control number
Authorization for SSA to Obtain Account Records From a Financial Institution and Request for Records (Medicare Part D Subsidy)
OMB 0960-0729 · SSA.
OMB 0960-0729
To determine if subsidy applicants or recipients qualify, or continue to qualify, for the subsidy, SSA conducts quality reviews of selected applications under the Medicare Quality Review System (OMB No. 0960-0707). As part of the quality review, SSA verifies claimants’ reported financial accounts as discussed in section 20 CFR 418.3420 of the Code of Federal Regulations. To complete this verification, SSA needs to obtain authorization from claimants to contact their financial institutions (FI) to verify the reported account balances. SSA uses Form SSA-4640 to: (1) obtain the individual’s consent to verify balances of FI accounts; and (2) obtain verification of such balances from the FI. The respondents are subsidy applicants or claimants and their FI.
The latest form for Authorization for SSA to Obtain Account Records From a Financial Institution and Request for Records (Medicare Part D Subsidy) expires 2026-07-31 and is listed under ICR 202103-0960-009.
Latest Forms, Documents, and Supporting Material
| 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) | Form |
| Form SSA-4640 Authorization... | Form |
 Addendum - 0729 (Final).docx | Supplementary Document |
| Supporting Statement - 0729 (Final).docx | Supporting Statement A |
 Medicare Part D Subsidy Applicants or Claimants |
Form |
| Medicare Part D Subsidy Applicants or Claimants |
Other-Revised PA Statement |
| Financial Institutions |
Form |
| Financial Institutions |
Other-Revised PA Statement |
All Historical Document Collections
| Reference | Filing | Received | Concluded | Action |
|---|---|---|---|---|
| 202606-0960-005 | Revision of a currently approved collection | 2026-06-26 | ||
| 202103-0960-009 | Revision of a currently approved collection | 2021-08-24 | Approved with change | |
| 201802-0960-005 | Revision of a currently approved collection | 2018-07-04 | Approved without change | |
| 201502-0960-008 | Extension without change of a currently approved collection | 2015-06-02 | Approved without change | |
| 201204-0960-005 | Revision of a currently approved collection | 2012-08-15 | Approved without change | |
| 200902-0960-009 | Revision of a currently approved collection | 2009-06-17 | Approved without change | |
| 200606-0960-007 | New collection (Request for a new OMB Control Number) | 2006-06-13 | Approved with change |
OMB Details
Medicare Part D Subsidy Applicants or Claimants
Federal Enterprise Architecture: Income Security - General Retirement and Disability
| Form | Name | Electronic access | 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) | Printable Only | Form |
Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.