Authorization for SSA to Obtain Account Records From A Financial Institution And Request For Records

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0293 can be found here:

Documents and Forms

Document Name Document Type
SSA-4641.doc Other-Revised SSA-4641-U2
SSA-4641-U2 Authorization for the Social Security Administration to SSA-4641-U2.pdf Form and Instruction
SSA-4641 OMB - SSA response (3).doc SSA-4641 OMB - SSA response (3).doc IC Document
OMB Questions Regarding Revisions to the SSA - Follow-Up.pdf OMB Questions Regarding Revisions to the SSA - Follow-Up.pdf IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Authorization for SSA to Obtain Account Records From A Financial Institution And Request For Records	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 416.203 20 CFR 416.200

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Revised SSA-4641-U2			SSA-4641.doc		No		Paper Only
Form and Instruction	SSA-4641-U2	Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records	SSA-4641-U2.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	500,000	500,000
Annual IC Time Burden (Hours)	50,000	50,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-4641 OMB - SSA response (3).doc	SSA-4641 OMB - SSA response (3).doc	01/11/2007
OMB Questions Regarding Revisions to the SSA - Follow-Up.pdf	OMB Questions Regarding Revisions to the SSA - Follow-Up.pdf	01/11/2007

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