Financial Disclosure for Civil Monetary Penalty (CMP) Debt

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0776 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-640 Financial Disclosure for Civil Monetary Penalty (CMP) Debt Form and Instruction
Revised PA Statement - SSA-640.pdf Other-Privacy Act Statement
SSA-640 Financial Disclosure for Civil Monetary Penalty (CMP) De SSA-640 - Revised Version.pdf Form and Instruction
SSA-640 - Current Version.pdf Current SSA-640 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Financial Disclosure for Civil Monetary Penalty (CMP) Debt	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 498

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-640	Financial Disclosure for Civil Monetary Penalty (CMP) Debt	SSA-640 - Revised Version.pdf		No		Paper Only
Other-Privacy Act Statement			Revised PA Statement - SSA-640.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 400	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	400	400
Annual IC Time Burden (Hours)	800	800
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-640	SSA-640 - Current Version.pdf	04/16/2015

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.