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OMB Control No: 0960-0293	ICR Reference No: 202604-0960-001
Status: Received in OIRA	Previous ICR Reference No: 202201-0960-009
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	Date Submitted to OIRA: 04/03/2026

	Requested	Previously Approved
Expiration Date	11/30/2027	11/30/2027
Responses	30,227,327	16,230,000
Time Burden (Hours)	1,670,247	1,381,666
Cost Burden (Dollars)	0	0

Abstract: SSA collects and verifies financial account information from individuals requesting a waiver of their Title II and Title XVI overpayments, as well as those who apply for, or currently receive (in the case of redetermination) Supplemental Security Income (SSI) payments. We require financial information from these individual’s to: (1) determine the eligibility of the applicant or recipient for SSI benefits; or (2) determine if a request to waive a Social Security overpayment defeats the purpose of the Act. If an individual provides incomplete or seemingly altered records, or if records are unavailable, SSA contacts his or her financial institutions to verify the existence; ownership; and value of accounts owned. Financial institutions need individuals to sign Form SSA-4641-F4, or contact SSA and use the Internet version, e4641, to authorize them to disclose the individual’s 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. We are submitting a non-substantive Change Request to request to add a new modality of completion for the SSA-4641. The new version will be published as an overprint (SSA-4641 OP1) and will not replace any existing modalities, we are updating disclosures and the Privacy Act Statement and we are moving the financial account identification from the authorization portion of the form to a new Part Two of the form and broken up the various parts of this multipurpose form into four sections.

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

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:
	87 FR 13783	03/10/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 31598	05/24/2022
Did the Agency receive public comments on this ICR? No

ICR Summary of Burden

	Total Request	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	30,227,327	16,230,000	13,997,327
Annual Time Burden (Hours)	1,670,247	1,381,666	288,581
Annual Cost Burden (Dollars)	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 2019, the burden was 542,667 hours. However, we are currently reporting a burden of 599,166 hours. This change stems from our new way of categorizing respondents into different groups (individual respondents versus financial institution respondents). Specifically, there was an increase in the number of responses from 16,000,000 to 16,230,000. In addition, due to the new three classifying groups of respondents, the burden per response estimates is now 2, 4, and 6 minutes, instead of just 2 and 6 minutes from before. These figures represent current Management Information data. Note: The total burden reflected in ROCIS is 1,381,666, while the burden cited in #12 of the Supporting Statement is 599,166. This discrepancy is because the ROCIS burden reflects the following components: field office waiting time + a rough estimate of a 30-minute, one-way, drive burden. In contrast, the chart in #12 of the Supporting Statement reflects actual burden.

Annual Cost to Federal Government: $27,572,580

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

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