E6-3797. 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. Disability Report-Appeal—20 CFR 404.1512, 416.912, 404.916(c), 416.1416(c)—0960-0144. The SSA-3441-BK is used to secure updated resource and condition information from claimants seeking reconsideration of denied disability benefits. The claimant also has the option of providing the information during a personal interview or through SSA's Internet application. This information assists the State Disability Determination Services and administrative law judges in preparing for appeals and hearings and in issuing a decision. Respondents are individuals who appeal denial of Social Security disability income and Supplemental Security Income (SSI) benefits, cessation of benefits, or who are requesting a hearing.

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

Collection method	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated annual burden
SSA-3441 (Paper Form)	404,506	1	30	202,253
Electronic Disability Collection System (EDCS)	635,873	1	30	317,937
I3441 (Internet Form)	72,341	1	60	72,341
Totals	1,112,720			592,531

Estimated Annual Burden: 592,531 hours.

2. Third Party Liability Information Statement—42 CFR 433.136-433.139—0960-0323. Identification of sources of third party insurance liable for medical care or services for Medicaid beneficiaries, which could be used to reduce Medicaid costs, is required under 42 U.S.C. 1396a(a)(25). Medicaid State agencies are mandated under 42 CFR 433.136-.139 to obtain this information on Medicaid applications and redeterminations as a condition of Medicaid eligibility. States are permitted to enter into agreements with the Commissioner of Social Security to make Medicaid eligibility determinations for aged, blind and disabled beneficiaries in those States. Applications for and redeterminations of SSI eligibility in jurisdictions with such agreements are also applications and redeterminations of Medicaid eligibility. Under these agreements, SSA obtains third party liability information using form SSA-8019 and provides that information to the State agencies which provide Medicaid under the terms of an approved plan in Title XIX of the Social Security Act. The Medicaid State agencies then use the information provided to attempt to bill any third parties liable for medical care, support or services for a beneficiary to guarantee that Medicaid remains the payer of last resort. The respondents are SSI applicants and beneficiaries.

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

Number of Respondents: 73,540.

Frequency of Response: 1.

Average Burden Per Response: 5 minutes.

Estimated Annual Burden: 6,128 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. Report to U.S. SSA by Person Receiving Benefits for a Child or Adult Unable to Handle Funds; & Report to U.S. SSA—0960-0049. SSA needs the information on Form SSA-7161-OCR-SM to monitor the performance of representative payees outside the U.S and the information on Form SSA-7162-OCR-SM to determine continuing entitlement to Social Security benefits and correct benefit amounts for beneficiaries outside the U.S. The respondents are individuals outside the U.S. who are receiving benefits either for someone else, or on their own behalf, under title II of the Social Security Act.

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

Form number	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated annual burden
SSA-7161-OCR-SM	30,000	1	15	7,500
SSA-7162-OCR-SM	227,000	1	5	18,917
Totals	257,000			26,417

Estimated Annual Burden: 26,417 hours.

2. Application for a Social Security Card—20 CFR 422.103-.110—0960-0066. Forms SS-5 (used in the United States) and SS-5-FS (used outside the United States) are used to apply for original and replacement Social Security cards. Changes are being made to these forms to reflect new statutory limits on the number of allowable replacement cards. The respondents are requestors of new or replacement Social Security cards.

Note:

This Notice is for the full clearance of the collection, which received a temporary emergency clearance through April 2006.

Application scenario	Number of annual respondents	Completion time (minutes)	Burden hours
Respondents who do not have to provide parents' SSNs	13,000,000	81/2	1,841,667
Respondents who are asked to provide parents' SSNs (for application for original SSN cards for children under age 18)	540,000	9	81,000
Applicants age 12 or older who need to answer additional questions so SSA can determine whether an SSN was previously assigned	40,000	91/2	6,333
Applicants asking for a replacement SSN card beyond the new allowable limits (i.e., who must provide additional documentation to accompany the application)	4,000	60	4,000
Totals	13,584,000		1,933,000

3. Work Activity Report—Employee—20 CFR 404.1520(b), 404.1571-.1576, 404.1584-.1593, and 416.971-.976—0960-0059. Form SSA-821-BK collects information that provides evidence necessary to determine initial or continuing eligibility for SSI or Social Security disability benefits. An individual's entitlement to benefits ends if he/she demonstrates an ability to perform substantial gainful activity (SGA). This form is used to determine whether work an individual performs in employment is at the SGA level. The respondents are Social Security disability applicants and beneficiaries and SSI applicants and recipients.

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

Number of Respondents: 300,000.

Frequency of Response: 1.

Average Burden Per Response: 45 minutes.

Estimated Annual Burden: 225,000 hours.

Dated: March 9, 2006.

Elizabeth A. Davidson,

Reports Clearance Officer, Social Security Administration.