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:
201112-0960-006
Status:
Historical Active
Previous ICR Reference No:
201103-0960-008
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:
No material or nonsubstantive change to a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
01/09/2012
Retrieve Notice of Action (NOA)
Date Received in OIRA:
01/06/2012
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
04/30/2013
04/30/2013
04/30/2013
Responses
5,000,000
0
3,000,000
Time Burden (Hours)
160,491
0
119,757
Cost Burden (Dollars)
0
0
0
Abstract:
The SSA-4641-U2 provides financial institutions with the applicant, recipient, or deemer's authorization to disclose records. The collected information helps determine eligibility for SSI benefits and for program evaluation purposes. Financial institutions, who are the respondents to this collection, are not legally required to complete the SSA-4641-U2. However, financial institution employees complete the form on an occasional basis at the request of the agency. The respondents are financial institutions used by SSI applicants, recipients and/or deemers. In this change request, we are increasing the burden to reflect the larger number of respondents we anticipate will use the form.
Authorizing Statute(s):
US Code:
42 USC 1383
Name of Law: Social Security Act
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:
74 FR 39728
08/07/2009
30-day Notice:
Federal Register Citation:
Citation Date:
74 FR 67945
12/21/2009
Did the Agency receive public comments on this ICR?
No
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 - SSA-4641-U2
SSA-4641-U2
Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records
Authorization for SSA to Obtain Account Records From A Financial Institution And Request for Records - e4641
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
5,000,000
3,000,000
0
0
2,000,000
0
Annual Time Burden (Hours)
160,491
119,757
0
0
40,734
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:
We are requesting to increase the public burden from 3,000,000 responses to 5,000,000 responses, as we now estimate that the number of e4641 transactions will increase to nearly 5 million transactions per year in fiscal year 2012.
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]?
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
Agency Contact:
Faye Lipsky 410 965-8783 faye.lipsky@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:
01/06/2012
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