Justification for Non-Substantive Changes to 0960-0293

Change Justification for Form SSA‑4641‑U2

Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records

20 CFR 416.200, 20 CFR 416.203

OMB No. 0960-0293

Form SSA-4641-U2 provides financial institutions with the SSI applicant or recipient’s authorization to disclose records. The purpose of obtaining the financial institution's records is to verify the existence, ownership, and value of financial accounts owned by SSI applicants, recipients and deemors. The financial institution's report is used, in part, to determine whether SSI resource eligibility requirements are met.

Revision to the Collection Instrument

SSA is requesting minor changes to the SSA-4641-U2 to improve the operational effectiveness of the form. The proposed changes below place no new burden on the public.

The proposed changes to the SSA-4641-U2 are as follows:

1. A field has been added to the top of pages two and three for the customer's name and Social Security number. These fields will be completed by an SSA employee. This change will help prevent processing errors in the event that page two and/or page three would become separated from page one during processing.

2. An SSA remarks section has been added to the top of page two. This remarks section is needed for cases where the SSA employee needs to provide special or unique search instructions to the financial institution.

3. The heading below has been moved to a lower position on page two to more clearly identify which section of the form is to be completed by the financial institution.

FOR COMPLETION BY THE FINANCIAL INSTITUTION REPRESENTATIVE

4. The bulleted instruction below has been moved from the bottom of page two, to the top of page two. This change is necessary, as the instruction requires completion by an SSA employee and the revised placement makes it easier for the financial institution representative to identify what account information is needed.

• Please provide information for the period ______________ through_____________ for the account number(s) listed above and any others held (either individually or jointly) by the above named customer.

Terms of Clearance:

This ICR is approved on the understanding that: 1) any necessary formatting issues (e.g. checkboxes) will be resolved prior to fielding the IC; 2) SSA will field the revised version of the form; 3) during development of the electronic version of this form, SSA will coordinate with OMB's privacy officer for SSA regarding security issues related to electronic submission of sensitive data; 4) upon development of the electronic version of this form, SSA will submit change requests for non-substantive changes to this form (substantive changes will still require a revision request); and 5) included in these change and/or revision requests, SSA will describe how SSA will ensure the secure transmission of sensitive data.

SSA addresses the above Terms as follows:

1) Any necessary formatting issues (e.g. checkboxes) will be resolved prior to fielding the IC;

SSA’s Response: The formatting issues as discussed in the previous clearance were incorporated into the form.

2) SSA will field the revised version of the form;

SSA’s Response: Due to cost issues associated with implementing the revised form and operational deficiencies discovered after approval of the revised version, SSA postponed release until the deficiencies as outlined in this request can be corrected. SSA will field the revised form (with the additions as outlined) upon approval.

3) During development of the electronic version of this form, SSA will coordinate with OMB's privacy officer for SSA regarding security issues related to electronic submission of sensitive data;

SSA’s Response: The Agency is in the process of developing a fully electronic verification system. As that system moves into the development phase, SSA will coordinate with OMB's privacy officer regarding security related issues.

4) Upon development of the electronic version of this form, SSA will submit change requests for non-substantive changes to this form (substantive changes will still require a revision request);

SSA’s Response: As the electronic process moves into the production phase, SSA will submit a change request for approval of any non-substantive changes to the form.

5) Included in these change and/or revision requests, SSA will describe how SSA will ensure the secure transmission of sensitive data.

SSA’s Response: Along with any change request, SSA will explain how sensitive data will be securely transmitted.