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

Forms and Documents

Document Name	Status
Form SSA-4641-U2 Authorization for SSA to Obtain Account Records From A Financial Institution And Request For Records - SSA-4641-U2 Form and Instruction	Modified
SSA-4641 - Contractor Offset for First Page (as mentioned in the Addendum).pdf Supplementary Document	2016-02-08
Addendum - 0293.docx Supplementary Document	2016-02-08
Supporting Statement - 0293.docx Supporting Statement A	2016-02-08

IC Document Collections

IC ID	Document Title	Status
9201	Authorization for SSA to Obtain Account Records From A Financial Institution And Request For Records - SSA-4641-U2 Form and Instruction	Modified
191430	Authorization for SSA to Obtain Account Records From A Financial Institution And Request for Records - e4641 and AFI System Other-Electronic Screens	Modified

ICR Details

OMB Control No: 0960-0293	ICR Reference No: 201602-0960-001
Status: Historical Active	Previous ICR Reference No: 201512-0960-008
Agency/Subagency: SSA	Agency Tracking No:
Title: Authorization for SSA to Obtain Account Records From A Financial Institution And Request For Records
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/25/2016
	Date Received in OIRA: 02/08/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2019	36 Months From Approved	03/31/2016
Responses	16,000,000	0	16,000,000
Time Burden (Hours)	550,167	0	540,053
Cost Burden (Dollars)	0	0	0

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Abstract: SSA collects and verifies financial information from individuals applying for Title II and Title XVI waiver determinations, as well as those who apply for, or currently receive (in the case of redetermination) Supplemental Security Income (SSI) payments. We require the financial information from these applicants to: (1) determine the eligibility of the applicant or recipient for Supplemental Security Income (SSI) benefits; or (2) determine if a request to waive a Social Security overpayment defeats the purpose of the Social Security Act. If the Title II and Title XVI waiver applicants, or the SSI claimants provide incomplete, unavailable, or seemingly altered records, SSA contacts their financial institutions to verify the existence, ownership, and value of accounts owned. Financial institutions need individuals to sign Form SSA-4641-F4, or work with SSA staff to complete one of SSA’s electronic applications, e4641 or the Access to Financial Institutions (AFI) screens, to authorize the individual’s financial institution to disclose records to SSA. The respondents are Title II and Title XVI recipients applying for waivers, or SSI applicants, recipients, and their deemors to determine SSI eligibility.

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Authorizing Statute(s): US Code: 12 USC 35, sections 3402-3404 Name of Law: Right to Financial Privacy Act of 1978
   PL: Pub.L. 114 - 74 834 Name of Law: Bipartisan Budget Act
   US Code: 42 USC 1383 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 43828	07/23/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 6586	02/08/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Authorization for SSA to Obtain Account Records From A Financial Institution And Request for Records - e4641 and AFI System
Authorization for SSA to Obtain Account Records From A Financial Institution And Request For Records - SSA-4641-U2	SSA-4641-U2	Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	16,000,000	16,000,000	0	0	0	0
Annual Time Burden (Hours)	550,167	540,053	0	0	10,114	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The burden increase stems from a change in the ratio between the paper and Internet modalities. We increased the number of paper forms to reflect our refined estimates on the number of paper forms sent via fax and US Mail to financial institutions by SSA field offices and SSA’s contractor. Since it takes longer to respond via paper form, this increased the total annual burden, even though the total number of respondents did not change. As we mention in our Addendum, if we notice a burden change due to the new AFI waiver requirements, we will inform SSA via Change Request

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Annual Cost to Federal Government: $11,820,128

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/08/2016

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