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:
0960-0729
ICR Reference No:
202103-0960-009
Status:
Active
Previous ICR Reference No:
201802-0960-005
Agency/Subagency:
SSA
Agency Tracking No:
Title:
Authorization for SSA to Obtain Account Records From a Financial Institution and Request for Records (Medicare Part D Subsidy)
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:
06/14/2023
Retrieve Notice of Action (NOA)
Date Received in OIRA:
08/24/2021
Terms of Clearance:
The agency made minor modifications to the supporting statement to clarify the operation of the collection and to increase the burden estimate. Prior to reapproval, the agency will brief OMB on opportunities to use Access to Financial Institutions (AFI) to facilitate this information collection.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
06/30/2026
36 Months From Approved
06/30/2023
Responses
10,000
0
10,000
Time Burden (Hours)
1,666
0
416
Cost Burden (Dollars)
0
0
0
Abstract:
To determine if subsidy applicants or recipients qualify, or continue to qualify, for the subsidy, SSA conducts quality reviews of selected applications under the Medicare Quality Review System (OMB No. 0960-0707). As part of the quality review, SSA verifies claimants’ reported financial accounts as discussed in section 20 CFR 418.3420 of the Code of Federal Regulations. To complete this verification, SSA needs to obtain authorization from claimants to contact their financial institutions (FI) to verify the reported account balances. SSA uses Form SSA-4640 to: (1) obtain the individual’s consent to verify balances of FI accounts; and (2) obtain verification of such balances from the FI. The respondents are subsidy applicants or claimants and their FI.
Authorizing Statute(s):
PL:
Pub.L. 108 - 173 101
Name of Law: Medicare Prescription Drug Benefit
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:
86 FR 22510
04/28/2021
30-day Notice:
Federal Register Citation:
Citation Date:
86 FR 46897
08/20/2021
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
Financial Institutions
SSA-4640
Authorization...
Medicare Part D Subsidy Applicants or Claimants
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)
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
10,000
10,000
0
0
0
0
Annual Time Burden (Hours)
1,666
416
0
0
1,250
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:
When we last cleared this IC in 2018, the burden was 416 hours. However, we are currently reporting a burden of 1,666 hours. This change stems from an increase in the completion time from 1 and 4 minutes to 10 minutes. After review, we determined the form takes longer than previously reported, which is reflected in the increase in completion time and the resulting change in burden. These figures represent current Management Information data.
Annual Cost to Federal Government:
$10,682
Does this IC contain surveys, censuses, or employ statistical methods?
No
Does this ICR request any personally identifiable information (see
OMB Circular No. A-130
for an explanation of this term)? Please consult with your agency's privacy program when making this determination.
Yes
Does this ICR include a form that requires a Privacy Act Statement (see
5 U.S.C. §552a(e)(3)
)? Please consult with your agency's privacy program when making this determination.
Yes
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?
No
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:
08/24/2021
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