View Information Collection Request (ICR) Package
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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0960-0293
ICR Reference No:
200609-0960-001
Status:
Historical Active
Previous ICR Reference No:
200410-0960-003
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 with change
Conclusion Date:
01/11/2007
Retrieve Notice of Action (NOA)
Date Received in OIRA:
09/25/2006
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.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
01/31/2010
36 Months From Approved
11/30/2007
Responses
500,000
0
500,000
Time Burden (Hours)
50,000
0
50,000
Cost Burden (Dollars)
0
0
0
Abstract:
Form SSA-4641-U2 provides financial institutions with the applicant or recipient's authorization to disclose records. Responses to the questions are used, in part, to determine whether the resources requirements are met in the Supplemental Security Income program. Respondents are any financial institutions used by SSI applicants, recipients, and/or deemors.
Authorizing Statute(s):
US Code:
42 USC 1383
US Code:
12 USC 35, sections 3402-3404
Name of Law: Right to Financial Privacy Act of 1978
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
71 FR 34814
06/13/2006
30-day Notice:
Federal Register Citation:
Citation Date:
71 FR 53485
09/11/2006
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
Authorization for SSA to Obtain Account Records From A Financial Institution And Request For Records
SSA-4641-U2
Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records
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
500,000
500,000
0
0
0
0
Annual Time Burden (Hours)
50,000
50,000
0
0
0
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:
Annual Cost to Federal Government:
$1,657,073
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]?
Uncollected
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
Uncollected
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
Uncollected
Is this ICR related to the Pandemic Response?
Uncollected
Agency Contact:
Elizabeth Davidson 411-965-0454 liz.davidson@ssa.gov
Common Form ICR:
No
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:
09/25/2006
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