Authorization for SSA to Obtain Account Records From a Financial Institution and Request for Records (Medicare Part D Subsidy)

OMB 0960-0729

Individuals who apply for the Medicare Part D subsidy must report all of their financial accounts. In cases where SSA chooses to verify applicants' account balances, we use Form SSA-4640 to: (1) obtain applicants' authorizations to contact their financial institutions and (2) verify balances with the financial institutions. The respondents are applicants for the Medicare Part D subsidy with financial accounts, and the institutions where those accounts are held.

The latest form for Authorization for SSA to Obtain Account Records From a Financial Institution and Request for Records (Medicare Part D Subsidy) expires 2021-10-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form SSA-4640 Medicare Part D Subsidy Applicants or Claimants Form
Form SSA-4640 Financial Institutions Form
Addendum - 0729 (Final).docx Supplementary Document
Supporting Statement - 0729 (Final).docx Supporting Statement A
Medicare Part D Subsidy Applicants or Claimants Form
Financial Institutions Form

All Historical Document Collections

202103-0960-009 Approved with change	Revision of a currently approved collection	2021-08-24
201802-0960-005 Approved without change	Revision of a currently approved collection	2018-07-04
201502-0960-008 Approved without change	Extension without change of a currently approved collection	2015-06-02
201204-0960-005 Approved without change	Revision of a currently approved collection	2012-08-15
200902-0960-009 Approved without change	Revision of a currently approved collection	2009-06-17
200606-0960-007 Approved with change	New collection (Request for a new OMB Control Number)	2006-06-13

OMB Details

Medicare Part D Subsidy Applicants or Claimants

Federal Enterprise Architecture: Income Security - General Retirement and Disability

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.