2017-25282. Agency Information Collection Activities: Proposed Request and Comment Request

The Social Security Administration (SSA) publishes a list of information collection packages requiring 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. This notice includes an extension of an OMB-approved information collection, new information collections, and revisions 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 ways to minimize burden on respondents, including the use of automated collection techniques or other forms of information technology. Mail, email, or fax your comments and recommendations on the information collection(s) to the OMB Desk Officer and SSA Reports Clearance Officer at the following addresses or fax numbers.

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

(SSA), Social Security Administration, OLCA, Attn: Reports Clearance Director, 3100 West High Rise, 6401 Security Blvd., Baltimore, MD 21235, Fax: [phone], Email address: [e-mail].

Or you may submit your comments online through www.regulations.gov,, referencing Docket ID Number [SSA-2017-0064].

I. The information collections below are pending at SSA. SSA will submit them to OMB within 60 days from the date of this notice. To be sure we consider your comments, we must receive them no later than January 22, 2018 Individuals can obtain copies of the collection instruments by writing to the above email address.

1. Fee Agreement for Representation Before the Social Security Administration—0960-NEW. SSA requires individuals who represent a claimant before the Social Security Administration and want to receive a fee for their services to obtain SSA's authorization of the fee under the Social Security Act (Act). We currently have two different, but mutually exclusive, methods to authorize a fee for a representative's services before SSA. SSA authorizes the fee either via the agreement process, if the representative submits the fee agreement before the first favorable decision, or the fee petition process, if the representative submits the request after the favorable decision. Currently SSA has no standardized form for the fee agreement process. Therefore, we created the SSA-1693 to make it easier for representatives to obtain the authorization for a fee agreement. SSA will use the information we collect on the SSA-1693 to review the request and authorize any fee to representatives who seek to charge and collect from a claimant. The respondents are the representatives who help claimants through the application process.

Type of Request: Request for a new information collection.

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-1693	600,000	1	12	120,000

2. Statement of Interpreter—0960-NEW. SSA and the Disability Determination Services (DDS) will use Form SSA-4321, Statement of Interpreter, when a person requiring an interpreter prefers to provide their own interpreter during an interview or conversation between the person requiring an interpreter and SSA or DDS. SSA will require the interpreter to sign Form SSA-4321, and confirm, among other things, that: (1) They will not knowingly give false information; (2) they will act as an interpreter and witness, and (3) they will accurately interpret the interview to the best of their ability. Section 205(a) of the Act, as amended in 42 U.S.C. 405(a), authorizes SSA collect this information.

Type of Request: Request for a new information collection.

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-4321	5,170,399	1	5	430,867

3. Statement of Living Arrangements, In-Kind Support, and Maintenance—20 CFR 416.1130-416.1148-0960-0174. SSA determines Supplemental Security Income (SSI) payment amounts based on applicants' and recipients' needs. We measure individuals' needs, in part, by the amount of income they receive, including in-kind support and maintenance in the form of food and shelter other people provide. SSA uses Form SSA-8006-F4 to determine if in-kind support and maintenance exists for SSI applicants and recipients. This information also assists SSA in determining the income value of in-kind support and maintenance SSI applicants and recipients receive. The respondents are individuals who apply for SSI payments, or who complete an SSI eligibility redetermination.

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

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-8006-F4	173,380	1	7	20,228

4. Claimant's Recent Medical Treatment—20 CFR 404.1512 and 416.912—0960-0292. When DDSs deny a claim at the reconsideration level, the claimant has a right to request a hearing before an administrative law judge (ALJ). For the hearing, SSA asks the claimant to complete and return the HA-4631 if the claimant's file does not reflect a current, complete medical history as the claimant proceeds through the appeals process. ALJs must obtain the information to update and complete the record and to verify the accuracy of the information. Through this process, ALJs can ascertain whether the claimant's situation changed. The ALJs and hearing office staff use the response to make arrangements for consultative examination(s) and the attendance of an expert witness(es), if appropriate. During the hearing, the ALJ offers any completed questionnaires as exhibits and may use them to: (1) Refresh the claimant's memory, and (2) shape their questions. The respondents are claimant's requesting hearings on entitlement to Old Age Survivors and Disabilty Insurance benefits or SSI payments.

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

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
HA-4631	200,000	1	10	33,333

5. Statement of Funds You Provided to Another and Statement of Funds You Received—20 CFR 416.1103(f)—0960-0481. SSA uses Forms SSA-2854 (Statement of Funds You Provided to Another) and SSA-2855 (Statement of Funds You Received) to gather information to verify if a loan is bona fide for SSI recipients. The SSA-2854 asks the lender for details on the transaction, and Form SSA-2855 asks the borrower the same basic questions independently. Agency personnel then compare the two statements; gather evidence if needed; and make a decision on the validity of the bona fide status of the loan.

For SSI purposes, we consider a loan bona fide if it meets these requirements:

• Must be between a borrower and lender with the understanding that the borrower has an obligation to repay the money;
• Must be in effect at the time the cash goes to the borrower, that is, the agreement cannot come after the cash is paid; and
• Must be enforceable under State law, often there are additional requirements from the State.

SSA collects this information at the time of initial application for SSI, or at any point when an individual alleges being party to an informal loan while receiving SSI. SSA collects information on the informal loan through both interviews and mailed forms. The agency's field personnel conduct the interviews and mail the form(s) for completion, as needed. The respondents are SSI recipients and applicants, and individuals who lend money to them.

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

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-2854	20,000	1	10	3,333
SSA-2855	20,000	1	10	3,333
Totals	40,000			6,666

6. Filing Claims Under the Federal Tort Claims Act—20 CFR 429.101-429.110—0960-0667. The Federal Tort Claims Act is the legal mechanism for compensating people injured by negligent or wrongful acts that occur during the performance of Federal employees' official duties. In accordance with the law, SSA accepts monetary claims filed under the Federal Tort Claims Act for damages against the United States; loss of property; personal injury; or death resulting from an SSA employee's wrongful act or omission. The regulation sections cleared under this information collection request require claimants to provide information SSA can use to investigate and determine whether to make an award, compromise, or settlement under the Federal Tort Claims Act. The respondents are individuals or entities making a claim under the Federal Tort Claims Act.

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

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
429.102; 429.1031	1	1	1	1
429.104(a)	11	1	5	1
429.104(b)	43	1	5	4
429.104(c)	1	1	5	0
429.106(b)	8	1	10	1
Totals	64			7
1 The 1 hour represents a placeholder burden. We are not reporting a burden for this collection because respondents complete OMB-approved Form SF-95.

7. Application for Extra Help with Medicare Prescription Drug Plan Costs—20 CFR 418.3101—0960-0696. The Medicare Modernization Act of 2003 mandated the creation of the Medicare Part D prescription drug coverage program and the provision of subsidies for eligible Medicare beneficiaries. SSA uses Form SSA-1020 or the Internet i1020, the Application for Extra Help with Medicare Prescription Drug Plan Costs, to obtain income and resource information from Medicare beneficiaries, and to make a subsidy decision. The respondents are Medicare beneficiaries applying for the Part D low-income subsidy.

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

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-1020 (paper application form)	531,715	1	30	265,858
i1020 (online application)	346,642	1	25	144,434
Field office interview	108,194	1	30	54,097
Totals	986,551			464,389

II. SSA submitted the information collections below to OMB for clearance. Your comments regarding these information collections would be most useful if OMB and SSA receive them 30 days from the date of this publication. To be sure we consider your comments, we must receive them no later than December 22, 2017. Individuals can obtain copies of the OMB clearance packages by writing to [e-mail].

1. Partnership Questionnaire—20 CFR 404.1080-404.1082(e)—0960-0025. SSA considers partnership income in determining entitlement to Social Security benefits. SSA uses information from Form SSA-7104 to determine several aspects of eligibility for benefits, including the accuracy of reported partnership earnings; the veracity of a retirement; and lag earnings where SSA needs this information to determine the status of the insured. The respondents are applicants for, and recipients of, Title II Social Security benefits who are reporting partnership earnings,

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

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-7104	12,350	1	30	6,175

2. Supplement to Claim of Person Outside the United States—20 CFR 422.505(b), 404.460, 404.463, and 42 CFR 407.27(c)—0960-0051. Claimants or beneficiaries (both United States (U.S.) citizens and aliens entitled to benefits) living outside the U.S. complete Form SSA-21 as a supplement to an application for benefits. SSA collects the information to determine eligibility for U.S. Social Security benefits for those months an alien beneficiary or claimant is outside the U.S., and to determine if tax withholding applies. In addition, SSA uses the information to: (1) Allow beneficiaries or claimants to request a special payment exception in an SSA restricted country; (2) terminate supplemental medical insurance coverage for recipients who request it, because they are, or will be, out of the U.S.; and (3) allow claimants to collect a lump sum death benefit if the number holder died outside the United States and we do not have information to determine whether the lump sum death benefit is payable under the Social Security Act. The respondents are Social Security claimants, or individuals entitled to Social Security benefits, who are, were, or will be residing outside the United States for three months or longer.

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

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
Paper SSA-21—U.S. Residents	510	1	14	119
Paper SSA-21—Residents of a Tax Treaty Country	2,751	1	9	413
Paper SSA-21—Nonresident aliens	1,835	1	8	245
Modernized Claims System (MCS) Macros SSA-21—U.S. Residents	1,325	1	11	243
MCS Macros SSA 21—Residents of a Tax Treaty Country	7,153	1	6	715
MCS Macros SSA 21—Nonresident aliens	4,769	1	5	397
Totals	18,343			2,132

Dated: November 17, 2017.

Naomi R. Sipple,

Reports Clearance Officer, Social Security Administration.