E7-555. Agency Information Collection Activities: Proposed Request and Comment Request

The Social Security Administration (SSA) publishes a list of information collection packages that will require clearance by the Office of Management and Budget (OMB) in compliance with Public Law 104-13, the Paperwork Reduction Act of 1995, effective October 1, 1995. The information collection packages that may be included in this notice are for new information collections, approval of existing information collections, revisions to OMB-approved information collections, and extensions (no change) of OMB-approved information collections.

SSA is soliciting comments on the accuracy of the agency's burden estimate; the need for the information; its practical utility; ways to enhance its quality, utility, and clarity; and on ways to minimize burden on respondents, including the use of automated collection techniques or other forms of information technology. Written comments and recommendations regarding the information collection(s) should be submitted to the OMB Desk Officer and the SSA Reports Clearance Officer. The information can be mailed and/or faxed to the individuals at the addresses and fax numbers listed below:

(OMB), Office of Management and Budget, Attn: Desk Officer for SSA, Fax: [phone].

(SSA), Social Security Administration, DCFAM, Attn: Reports Clearance Officer, 1333 Annex Building, 6401 Security Blvd., Baltimore, MD 21235. Fax: [phone].

I. The information collections listed below are pending at SSA and will be submitted to OMB within 60 days from the date of this notice. Therefore, your comments should be submitted to SSA within 60 days from the date of this publication. You can obtain copies of the collection instruments by calling the SSA Reports Clearance Officer at 410-965-0454 or by writing to the address listed above.

1. Questionnaire about Employment or Self-Employment Outside the United States—20 CFR 404.401(b)(1), 404.415, 404.417—0960-0050. The information collected on the SSA-7163 is needed to determine whether work performed by beneficiaries outside the United States is cause for deductions from their monthly Social Security Title II benefits; to determine which of two work tests (foreign test or regular test) is applicable; and to determine the months, if any, for which deductions should be imposed. The respondents are Title II beneficiaries living and working outside the United States.

Type of Request: Extension of an OMB-approved information collection.

Number of Respondents: 20,000.

Frequency of Response: 1.

Average Burden Per Response: 12 minutes.

Estimated Annual Burden: 4,000 hours.

2. Complaint Form for Allegations of Discrimination in Programs or Activities Conducted by the Social Security Administration—0960-0585. The information collected on form SSA-437 is used by SSA to investigate and formally resolve complaints of discrimination based on race, color, sex, age, religion, disability, retaliation, and national origin, including limited or no ability with English in any program or activity conducted by SSA. A person who believes that he or she has been discriminated against on any of the above bases may file a written complaint of discrimination. The information will be used to identify the complainant; identify the alleged discriminatory act; ascertain the date of such alleged act; obtain the identity of any individual(s) with information about the alleged discrimination; and ascertain other relevant information that would assist in the investigation and resolution of the complaint. The respondents are individuals who believe they have been discriminated against by SSA or by SSA's employees, contractors or agents in programs or activities conducted by SSA.

Type of Request: Extension of an OMB-approved information collection.

Number of Respondents: 140.

Frequency of Response: 1.

Average Burden Per Response: 60 minutes.

Estimated Annual Burden: 140 hours.

3. Work Incentives Planning and Assistance Program (formerly the BPAO Program)—0960-0629. Like the Benefits Planning Assistance Outreach (BPAO) program which it replaces, the Work Incentives Planning and Assistance (WIPA) program collects identifying information from the project sites and the community work incentives coordinators. In addition, data are collected from the beneficiaries on background employment, training, benefits and work incentives. SSA is interested in identifying beneficiary outcomes under the WIPA program to determine the extent to which beneficiaries with disabilities achieve their employment, financial and health care goals. The data will also be valuable to SSA in its analysis and future planning for Social Security Disability Insurance and Supplemental Security Income (SSI) programs.

Type of Request: Revision of an OMB-approved information collection.

Estimated Annual Burden: 5,019 hours.

Respondent	Number of annual responses	Frequency of response	Average burden per response (minutes)	Estimated annual burden hours
Site	147	1	2	5
CWIC	422	1	2	14
Beneficiary	60,000	1	5	5,000
Totals	60,569			5,019

4. Expanded Monitoring Site Review Questionnaire for Volume and Fee for Service Payees (SSA-637); Expanded Monitoring Site Review Beneficiary Interview Form (SSA-639)—20 CFR 404.2035, 404.2065, 416.665, 416.701, 416.708—0960-0633. In situations where a Social Security beneficiary or SSI recipient is incompetent or physically unable to take care of his or her own affairs, SSA may pay Social Security benefits and/or SSI payments to a relative, another person, or an organization when the best interest of the beneficiary will be served. In certain situations, SSA conducts site reviews to ensure that payees are carrying out their responsibilities according to representative payment policies and procedures. SSA is also able to identify poor payee performance, uncover misuse and initiate corrective action. Triennial site reviews are conducted for fee-for-service payees and all volume payees (i.e., organizations serving 100 or more beneficiaries and individuals serving 20 or more beneficiaries). The reviews include a face-to-face meeting with the payee (and appropriate staff), examination/verification of a sample of beneficiary records and supporting documentation, and usually include beneficiary (if competent adult) or custodian (if different from payee) interviews. Forms SSA-637 and SSA-639 are used to record the information collected during these interviews. The respondents are certain representative payees and also competent Social Security beneficiaries.

Type of Request: Revision of an OMB-approved information collection.

Estimated Annual Burden: 3,538 hours.

Form No.	Number of respondents	Reports annually	Time per response (minutes)	Total hours
SSA-637	1,763	1	75	2,204
SSA-639	8,001	1	10	1,334
Totals	9,764			3,538

5. Direct Deposit Sign-Up Form (Country)—31 CFR 210—0960-0686. This form captures the direct deposit information for an account at a foreign financial institution. Our International Direct Deposit program allows beneficiaries living abroad to have their benefits deposited to an account at a financial institution outside the U.S. Routing account number information varies slightly for each country, so we use a variation of the SF-1199 A for each country. The respondents are Social Security beneficiaries residing abroad.

Type of Request: Extension of an OMB-approved information collection.

Number of Respondents: 5,000.

Frequency of Response: 1.

Average Burden Per Response: 5 minutes.

Estimated Annual Burden: 417 hours.

6. Certification of Prisoner Identity Information—20 CFR 422.107—0960-0688. When a valid agreement is in place, prison officials will verify the identity of certain incarcerated U.S. citizens who need replacement Social Security cards. Information the prison officials provide will be taken from the official prison files and will be transcribed on their letterhead. This information will be used to establish the applicant's identity in the Social Security card process. The respondents are prison officials that certify identity of prisoners applying for replacement Social Security cards.

Type of Request: Extension of an OMB-approved information collection.

Number of Respondents: 1,000.

Frequency of Response: 200.

Average Burden Per Response: 3 minutes.

Estimated Annual Burden: 10,000 hours.

II. The information collections listed below have been submitted to OMB for clearance. Your comments on the information collections would be most useful if received by OMB and SSA within 30 days from the date of this publication. You can obtain a copy of the OMB clearance packages by calling the SSA Reports Clearance Officer at 410-965-0454, or by writing to the address listed above.

1. Certification of Period of Temporary Institutionalization and Need to Maintain Home—20 CFR 416.212(b)(1)—0960-0516. SSA is required by law to collect the information necessary to establish eligibility for continued SSI payments for temporarily institutionalized individuals. Sections 1611(e)(1)(G)&(H) of the Social Security Act require the Commissioner to establish procedures for determining that a physician has certified that the period of confinement is not likely to exceed 3 months, and for determining that the recipient needs to continue to maintain and provide for the expense of a home or living arrangement.

Type of Request: Extension of an OMB-approved information collection.

Number of Respondents: 60,000.

Frequency of Response: 1.

Average Burden Per Response: 5 minutes.

Estimated Annual Burden: 5,000 hours.

2. Blood Donor Locator Service (BDLS)—20 CFR 401.200—0960-0501. This regulation requires requesting State agencies to provide the names and Social Security Numbers of blood donors, and a statement that the donor's blood tested positive for Human Immunodeficiency Virus (HIV) to SSA's Blood Donor Locator Service when blood donor facilities have identified donors as testing positive for HIV. This information is used by SSA to furnish the State agencies with the blood donors' address information for the purpose of notifying them. Respondents are State agencies acting on behalf of blood donor facilities.

Type of Request: Extension of an OMB-approved information collection.

Number of Respondents: 10.

Frequency of Response: 5.

Number of Responses: 50.

Average Burden Per Response: 15 minutes.

Estimated Annual Burden: 13 hours.

3. Pre-1957 Military Service—Federal Benefit Questionnaire—20 CFR 404.1301-404.1371—0960-0120. Sections 217(a) through (e) of the Social Security Act provide for the crediting of military service before 1957 to the wage earner's record. This form collects specific information about other Federal, military or civilian benefits the wage earner may receive when the applicant indicates both pre-1957 military service and the receipt of Federal benefit. This data is then used in the claims adjudication process to grant gratuitous military wage credits when applicable. This form is used to solicit sufficient information to make a determination of eligibility. Respondents are applicants for Social Security benefits on a record where the wage earner has pre-1957 military service.

Type of Request: Extension of an OMB-approved information collection.

Number of Respondents: 5,000.

Frequency of Response: 1.

Average Burden Per Response: 10 minutes.

Estimated Annual Burden: 833 hours.

4. Statement of Household Expenses and Contributions—20 CFR 416.1130-416.1148—0960-0456. SSA needs the information about household expenses and contributions, which is collected on Form SSA-8011-F3, to determine whether the individual receives in-kind support and maintenance. This is necessary to determine eligibility for SSI and the amount payable. This form is not used for all claims and post eligibility determinations; rather, it is used only when it is necessary to document in-kind support and maintenance and only in cases where the householder's corroboration is needed. Respondents are SSI applicants and/or recipients.

Type of Request: Extension of an OMB-approved information collection.

Number of Respondents: 400,000.

Frequency of Response: 1.

Average Burden Per Response: 15 minutes.

Estimated Annual Burden: 100,000 hours.

Dated: January 10, 2007.

Elizabeth A. Davidson,

Reports Clearance Officer, Social Security Administration.