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HA-4633 - Paper Version
Claimant's Work Background
OMB: 0960-0300
IC ID: 9205
OMB.report
SSA
OMB 0960-0300
ICR 202508-0960-003
IC 9205
( )
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
HA-4633 - 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 404.1565(b)
20 CFR 416.912(a)
20 CFR 404.1520(a)(4)
20 CFR 416.920(a)(4)
20 CFR 404.1512(a)
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
HA-4633
Claimant's Work Background
HA-4633 - Revised Version.pdf
www.ssa.gov (mySocial Security Account - Upload Documents)
No
Fillable Fileable Signable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Income Security
Subfunction:
General Retirement and Disability
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
48,450
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Requested
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
48,450
0
0
16,150
0
32,300
Annual IC Time Burden (Hours)
16,150
0
0
0
0
16,150
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
HA-4633 - Prior to Implementation of the PRW Rule
HA-4633 (Prior to PRW Rule).pdf
03/11/2026
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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