2014-28562. 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 revisions and an extension 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-2014-0074].

I. The information collection below is pending at SSA. SSA will submit it 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 February 3, 2015. Individuals can obtain copies of the collection instruments by writing to the above email address.

Application for Mother's or Father's Insurance Benefits—20 CFR 404.339-404.342, 20 CFR 404.601-404.603—0960-0003. Section 202(g) of the Social Security Act provides for the payment of monthly benefits to the widow or widower of an insured individual if the surviving spouse is caring for the deceased worker's child (who is entitled to Social Security benefits). SSA uses the information on Form SSA-5-BK to determine an individual's eligibility for mother's or father's insurance benefits. The respondents are individuals caring for a child of the deceased worker who is applying for mother's or father's insurance benefits under the Old Age, Survivors, and Disability Insurance program (OASDI).

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

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Total estimated annual burden (hours)
SSA-5-F6 (paper)	1,611	1	15	403
MCS	26,045	1	15	6,511
MCS/Signature Proxy	26,044	1	14	6077
Total	53,700			12,991

II. SSA submitted the information collections below to OMB for clearance. Your comments regarding the 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 January 5, 2015. Individuals can obtain copies of the OMB clearance package by writing to [e-mail].

1. Letter to Employer Requesting Information About Wages Earned by Beneficiary—20 CFR 416.703, 404.801 & 404.820—0960-0034. Social Security disability recipients receive payments based on their inability to engage in substantial gainful activity (SGA) because of a physical or mental condition. If the recipients work, SSA must evaluate and determine if they continue to meet the disability requirements of the law. Therefore, we use Form SSA-L725 to request monthly earnings information from the recipient's employer. We then use the earnings data to determine whether the recipient is engaging in SGA, since work after a recipient becomes entitled to benefits can cause a cessation of disability. The respondents are businesses that employ Social Security disability recipients.

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-L725	150,000	1	40	100,000

2. Letter to Employer Requesting Wage Information—0960-0138. SSA must establish and verify wage information for Supplemental Security Income (SSI) applicants and recipients when determining SSI eligibility and payment amounts. SSA uses Form SSA-L4201 to collect wage data from employers. SSA uses the information to determine eligibility and proper payment amounts for SSI applicants and recipients. The respondents are employers of SSI applicants and recipients.

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-L4201	133,000	1	30	66,500

3. Statement of Living Arrangements, In-Kind Support, and Maintenance—20 CFR 416.1130-416.1148—0960-0174. SSA determines 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 provided by other persons. 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 Disability Determinations Services (DDS) 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 has 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 OASDI 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. Certification of Low Birth Weight for SSI Eligibility of Funds You Provided to Another and Statement of Funds You Received—20 CFR 416.931, 416.926a(m), and 416.924—0960-0720. Hospitals and claimants use Form SSA-3380 to provide medical information to local field offices (FO) and the DDS on behalf of infants with low birth weight. FOs use the form as a protective filing statement and the medical information to make presumptive disability findings, which allow expedited payment to eligible claimants. DDSs use the medical information to determine disability and continuing disability. The respondents are hospitals and claimants who have information identifying low birth weight babies and their medical conditions.

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-3380	28,125	1	15	7,031

6. Request to Show Cause for Failure to Appear—20 CFR 404.938, 20 CFR 416.1438, and 20 CFR 404.957(a)(ii)—0960-0794. When claimants who requested a hearing before an ALJ fail to appear at their scheduled hearing, the ALJ may reschedule the hearing if the claimants establish good cause for missing the hearings. To establish good cause, claimants must show one of the following: (1) SSA did not properly notify the claimant of the hearing, or (2) an unexpected event occurred without sufficient time for the claimant to request a postponement. The claimants can use paper Form HA-L90 to provide their reason for not appearing at their scheduled hearings; or the claimants' representatives can use Electronic Records Express to submit the HA-L90 online. If the ALJ determines the claimants established good cause for failure to appear at the hearing, the ALJ will schedule a supplemental hearing; if not, the ALJ will make a claims eligibility determination based on the claimants' evidence of record. Respondents are claimants, or their representatives, seeking to establish good cause for failure to appear at a scheduled hearing before an ALJ.

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)
HA-L90 (paper or Electronic Records Express)	40,000	1	10	6,667

Dated: December 2, 2014.

Faye Lipsky,

Reports Clearance Officer, Social Security Administration.