Authorization for SSA to
Obtain Account Records From A Financial Institution And Request For
Records
No
material or nonsubstantive change to a currently approved
collection
No
Regular
04/03/2026
Requested
Previously Approved
11/30/2027
11/30/2027
30,227,327
16,230,000
1,670,247
1,381,666
0
0
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.
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.
$27,572,580
No
Yes
Yes
No
No
No
No
Faye Lipsky 410 965-8783
faye.lipsky@ssa.gov
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:
(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;
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.
04/03/2026
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Authorization for SSA to Obtain Account Records From A Financial Institution And Request For Records - Individuals (Paper and Electronic)