Claimant's Medication - PDF/Paper Version

Claimant's Medications

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 Version.pdf Form
HA-4632 Claimant's Medications HA-4632 - Revised Version.pdf Form
HA-4632 - Current Version.pdf Current HA-4632 IC Document
HA-4632 - Current Version.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 Version.pdf		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: 53,200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	53,200	33,200	20,000
Annual IC Time Burden (Hours)	39,900	34,900	5,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Current HA-4632	HA-4632 - Current Version.pdf	11/02/2021

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