Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Authorization for SSA to Obtain Account Records From a Financial Institution and Request for Records (Medicare) (As completed by the claimant.) Modified 5000 83 0 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 finanical institution.) Modified 5000 333 0 Form SSA-4640
Total burden requested under this ICR: 10000 416 0  
To view an IC, click on IC Title