Claimant's Medication - PDF/Paper Version

Claimant's Medications

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0289 can be found here:

Documents and Forms

Document Name Document Type
Form HA-4632 Claimant's Medication - PDF/Paper Version Form
HA-4632 Claimant's Medications HA-4632 (revised).pdf Form
HA-4632 (current).pdf Current HA-4632 IC Document

Information Collection (IC) Details

IC Title:	Claimant's Medication - PDF/Paper Version	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.1512 20 CFR 416.912

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HA-4632	Claimant's Medications	HA-4632 (revised).pdf		Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20,000	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	20,000	20,000
Annual IC Time Burden (Hours)	5,000	5,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Current HA-4632	HA-4632 (current).pdf	04/25/2018

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