Financial Disclosure for Civil Monetary Penalty (CMP) Debt

ICR 200903-0960-006

OMB: 0960-0776

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
New
Supporting Statement A
2009-05-07
IC Document Collections
ICR Details
0960-0776 200903-0960-006
Historical Active
SSA
Financial Disclosure for Civil Monetary Penalty (CMP) Debt
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 10/22/2009
Retrieve Notice of Action (NOA) 06/29/2009
  Inventory as of this Action Requested Previously Approved
10/31/2012 36 Months From Approved
400 0 0
800 0 0
0 0 0

SSA uses Form SSA-640, Financial Disclosure for Civil Monetary Penalty (CMP)Debt to obtain the information necessary to determine a repayment rate for individuals who have had a civil monetary penalty imposed on them for various fraudulent conduct related to SSA-administered programs. SSA needs financial information to ensure the repayment rate is in the best interest of both the individual and the agency. The respondents are recipients of Social Security benefits and nonentitled individuals who must pay a civil monetary penalty.

US Code: 42 USC 1320 Name of Law: Public Health and Welfare
  
None

Not associated with rulemaking

  74 FR 7506 02/17/2009
74 FR 18782 04/24/2009
No

1
IC Title Form No. Form Name
Financial Disclosure for Civil Monetary Penalty (CMP) Debt SSA-640 Financial Disclosure for Civil Monetary Penalty (CMP) Debt

  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 400 0 0 400 0 0
Annual Time Burden (Hours) 800 0 0 800 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
This is a new information collection that will increase the public reporting burden.

$4,312
No
No
Uncollected
Uncollected
No
Uncollected
John Biles 410 965-3758 John.Biles@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.
06/29/2009


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