Financial Disclosure for Civil Monetary Penalty (CMP) Debt

ICR 201203-0960-006

OMB: 0960-0776

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supporting Statement A
2012-06-18
Supplementary Document
2012-04-16
IC Document Collections
ICR Details
0960-0776 201203-0960-006
Historical Active 200903-0960-006
SSA
Financial Disclosure for Civil Monetary Penalty (CMP) Debt
Revision of a currently approved collection   No
Regular
Approved without change 08/31/2012
Retrieve Notice of Action (NOA) 06/19/2012
  Inventory as of this Action Requested Previously Approved
08/31/2015 36 Months From Approved 10/31/2012
400 0 400
800 0 800
0 0 0

SSA uses Form SSA-640, Financial Disclosure for Civil Monetary Penalty (CMP)Debt, to obtain the information we need to determine a repayment rate for individuals for whom we have imposed a civil monetary penalty for 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: Social Security Act
  
None

Not associated with rulemaking

  77 FR 19406 03/30/2012
77 FR 35739 06/14/2012
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 400 400 0 0 0 0
Annual Time Burden (Hours) 800 800 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$4,312
No
No
No
No
No
Uncollected
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.
06/19/2012


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