Certificate of Incapacity

Documents and Forms

Document Name Document Type
Form SSA-604 Certificate of Incapacity Form and Instruction
SSA-604 Certificate of Incapacity SSA-604 (revised).pdf Form and Instruction
SSA-604 (current).pdf Certificate of Incapacity (current verison) IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Certificate of Incapacity	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 5 CFR 890.302(d)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-604	Certificate of Incapacity	SSA-604 (revised).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: 50	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	38	38
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Certificate of Incapacity (current verison)	SSA-604 (current).pdf	07/18/2019

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