HA-4633 - Electronic Records Express Submissions

Claimant's Work Background

Documents and Forms

Document Name Document Type
Form HA-4633 HA-4633 - Electronic Records Express Submissions Form and Instruction
Revised PA and PRA Statements - HA-4633.pdf www.ssa.gov Other-Revised PA and PRA Statements
HA-4633 Claimant’s Work Background HA-4633 - Revised Version.pdf www.ssa.gov Form and Instruction
HA-4633 - Current Version.pdf Current HA-4633 IC Document

Information Collection (IC) Details

IC Title:	HA-4633 - Electronic Records Express Submissions	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.1512(a) 20 CFR 404.1520(a)(4) 20 CFR 404.1565(b) 20 CFR 416.912(a) 20 CFR 416.920(a)(4) 20 CFR 416.965(b)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	HA-4633	Claimant’s Work Background	HA-4633 - Revised Version.pdf	www.ssa.gov	Yes	Yes	Fillable Fileable Signable
Other-Revised PA and PRA Statements			Revised PA and PRA Statements - HA-4633.pdf	www.ssa.gov	Yes	No	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 136,800	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	136,800	136,800
Annual IC Time Burden (Hours)	34,200	34,200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Current HA-4633	HA-4633 - Current Version.pdf	08/21/2020

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