E9-9318. 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 (Pub. L.) 104-13, the Paperwork Reduction Act of 1995, effective October 1, 1995. This notice includes revisions and extensions of OMB-approved Information Collections and a new collection.

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 the burden on respondents, including the use of automated collection techniques or other forms of information technology. Mail, e-mail, or fax your comments and recommendations on the information collection(s) to the OMB Desk Officer and the SSA Reports Clearance Officer to the addresses or fax numbers listed below.

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

(SSA), Social Security Administration, DCBFM, Attn: Reports Clearance Officer, 1332 Annex Building, 6401 Security Blvd., Baltimore, MD 21235. Fax: [phone]. E-mail address: [e-mail].

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 June 23, 2009. Individuals can obtain copies of the collection instrument by calling the SSA Reports Clearance Officer at 410-965-3758 or by writing to the e-mail address listed above.

1. Social Security Benefits Application—20 CFR 404.310-.311, .315-.322, .330-.333, .601-.603, and .1501-.1512—0960-0618. This collection comprises the various application modalities for retirement, survivors, and disability benefits. These modalities include paper forms (SSA Forms SSA-1, SSA-2, and SSA-16), Modernized Claims System (MCS) screens for in-person field office interview applications, and the Internet-based iClaim application. This information collection request (ICR) will expand the potential user base for the iClaim.

Type of Collection: Revision to an existing OMB-approved information collection.

Paper Forms/Accompanying MCS Screens Burden Information:

Form SSA-1

Collection method	Number of respondents	Frequency of response	Average burden per response (min)	Estimated annual burden (hours)
MCS	172,200	1	11	31,570
MCS/Signature Proxy	1,549,800	1	10	258,300
Paper	21,000	1	11	3,850
Medicare-only MCS	299,000	1	7	34,883
Medicare-only Paper	1,000	1	7	117
Totals	2,043,000			328,720

Form SSA-2

Collection method	Number of respondents	Frequency of response	Average burden per response (min)	Estimated annual burden (hours)
MCS	36,860	1	15	9,215
MCS/Signature Proxy	331,740	1	14	77,406
Paper	3,800	1	15	950
Totals	372,400			87,571

Form SSA-16

Collection method	Number of respondents	Frequency of response	Average burden per response (min)	Estimated annual burden (hours)
MCS	218,657	1	20	72,886
MCS/Signature Proxy	1,967,913	1	19	623,172
Paper	24,161	1	20	8,054
Totals	2,210,731			704,112

iClaim Burden Information

Form type	Number of respondents	Frequency of response	Average burden per response (min)	Estimated annual burden (hours)
iClaim 3rd Party	28,118	1	15	7,030
iClaim Applicant after 3rd Party Completion	28,118	1	5	2,343
First Party iClaim	541,851	1	15	135,463
Medicare-only iClaim	200,000	1	10	33,333
Totals	798,087			178,169

Aggregate Public Reporting Burden: 1,298,572 hours.

2. Electronic Records Express (Third Parties)—20 CFR 404.1700-404.1715—0960-0767. Electronic Records Express is an online system that enables medical providers and various third party representatives to submit disability claimant information electronically to SSA as part of the disability application process. We are revising this OMB number to add new functionality for third parties who use this system.

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

Number of Respondents: 66,000.

Frequency of Response: 40.

Average Burden per Response: 1 minute.

Estimated Annual Burden: 44,000 hours.

3. Registration of Individual for Appointed Representative Services—0960-0732. SSA uses Form SSA-1699 to register the following people:

• Individuals appointed as representatives;
• Individuals who will perform advocacy services on behalf of an appointed representative;
• Individuals who will act on behalf of an appointed representative and want access to our electronic services;
• Individuals who will serve as administrators for an entity appointed as a representative.

By registering these individuals, SSA: (1) Authenticates and authorizes them to do business with us; (2) allows them access to our records for the claimants they represent; (3) facilitates direct payment of authorized fees to appointed representatives; and (4) collects information needed to meet Internal Revenue Service (IRS) requirements to issue specific IRS forms, if we pay these representatives in excess of a specific amount ($600).

This ICR is for changes we will implement later in the year. The respondents are appointed claimant representatives.

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

Collection method	Number of respondents	Frequency of response	Average burden per response (min)	Estimated annual burden (hours)
SSA-1699 (paper form)	52,800	1	30	26,400
Internet-based SSA-1699	13,200	1	22	4,840
Totals	66,000			31,240

4. State Agency Report of Obligations for SSA Disability Programs (SSA-4513); Time Report of Personnel Services for Disability Determination Services (SSA-4514); State Agency Schedule of Equipment Purchased for SSA Disability Programs (SSA-871)—20 CFR 404.1626—0960-0421. SSA uses Forms SSA-4513, SSA-4514, and SSA-871 to collect data necessary for detailed analysis and evaluation of costs State Disability Determination Services (DDS) incur in making disability determinations for SSA. SSA also utilizes the data to determine funding levels for each DDS. Respondents are State DDSs.

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

Number of Respondents: 54.

Estimated Annual Burden: 756 hours.

	Respondents	Frequency of response	Total annual responses	Average burden per response (min)	Estimated annual burden (hours)
SSA-4513 & Addendum	54	4	216	90	324
SSA-4514	54	4	216	90	324
SSA-871	54	4	216	30	108
Total	162				756

5 . Application for Special Benefits for World War II Veterans—20 CFR 408, Subparts B, C and D—0960-0615. Title VIII of the Social Security Act (Special Benefits for Certain World War II Veterans) allows a qualified World War II veteran who resides outside the United States to receive monthly payments. The regulations set out the requirements an individual needs to meet to qualify for and become entitled to Special Veterans Benefits (SVB). SSA uses Form SSA-2000-F6 to elicit the information necessary to determine entitlement to SVB. The respondents are individuals who are applying for SVB under Title VIII of the Social Security Act.

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

Section No.	Number of respondents	Frequency of response	Average burden per response (min)	Estimated annual burden (hours)
§ 408.202(d); § 408.210; § 408.230(a); § 408.305; §§ 408.310-.315	100	1	20	33
§ 408.232(a)	1	1	15	0
§ 408.320	1	1	15	0
§ 408.340	1	1	15	0
§ 408.345	1	1	15	0
§ 408.351(d) & (f)	1	1	30	1
§ 408.355(a)	1	1	15	0
§ 408.360(a)	1	1	15	0
§ 408.404(c)	6	1	15	2
§§ 408.410-.412	6	1	15	2
§ 408.420(a), (b)	71	1	15	18
§§ 408.430 & .432	66	1	30	33
§ 408.435(a), (b), (c)	71	1	15	18
§ 408.437(b), (c), (d)	6	1	30	3
Totals	333			110

II. SSA has submitted the information collections listed below to OMB for clearance. Your comments on the information collections would be most useful if OMB and SSA receive them within 30 days from the date of this publication. To be sure we consider your comments, we must receive them no later than May 26, 2009. You can obtain a copy of the OMB clearance packages by calling the SSA Reports Clearance Officer at 410-965-3758 or by writing to the above e-mail address.

1. Request for Withdrawal of Application—20 CFR 404.640—0960-0015. Individuals complete Form SSA-521 to request withdrawal of an application for benefits. SSA uses the information from Form SSA-521 to process the request for withdrawal. The respondents are applicants for Old Age, Survivors, and Disability Insurance (OASDI) benefits.

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

Number of Respondents: 100,000.

Frequency of Response: 1.

Average Burden per Response: 5 minutes.

Estimated Annual Burden: 8,333 hours.

2. Application for Search of Census Records for Proof of Age—20 CFR 404.716—0960-0097. SSA uses the information from Form SSA-1535-U3 to provide the Census Bureau with identification information sufficient to allow an accurate search of census records to establish proof of age for an individual applying for Social Security benefits. When preferred evidence of age is not available and the available evidence is not convincing, SSA may request the U.S. Department of Commerce, Bureau of the Census, to search its records to establish a claimant's date of birth. The Census Bureau uses the information from a completed, signed SSA-1535-U3 to bill SSA for the search. The respondents are applicants for Social Security benefits who need to establish their date of birth as a factor of entitlement.

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

Number of Respondents: 18,030.

Frequency of Response: 1.

Average Burden per Response: 12 minutes.

Estimated Annual Burden: 3,606 hours.

3. Workers' Compensation/Public Disability Questionnaire—20 CFR 404.408—0960-0247. Section 224 of the Social Security Act provides for the reduction of disability insurance benefits (DIB) when the combination of DIB and any workers' compensation (WC) and/or certain Federal, State, or local public disability benefits (PDB) exceeds 80 percent of the worker's average current earnings. SSA uses Form SSA-546 to collect the data necessary to determine if the worker's receipt of WC/PDB payments will cause a reduction of DIB. The respondents are applicants for Title II DIB.

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

Number of Respondents: 100,000.

Frequency of Response: 1.

Average Burden per Response: 15 minutes.

Estimated Annual Burden: 25,000 hours.

4. Claimant's Medication—20 CFR 404.1512, 416.912—0960-0289. In cases where a claimant is requesting a hearing after denial of his or her claim for Social Security benefits, SSA uses Form HA-4632 to request information from the claimant regarding the medications he or she is using. This information helps the Administrative Law Judge hearing the case to inquire fully into the medical treatment the claimant is receiving and the effect of medications on the claimant's medical impairments and functional capacity. Respondents are applicants for OASDI benefits and/or Supplemental Security Income (SSI) payments.

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

Number of Respondents: 200,000.

Frequency of Response: 1.

Average Burden per Response: 15 minutes.

Estimated Annual Burden: 50,000 hours.

5. Statement of Funds You Provided to Another and Statement of Funds You Received—20 CFR 416.1103(f)—0960-0481. Forms SSA-2854 and SSA-2855 collect information on an SSI beneficiary's allegations that he or she borrowed funds informally from a non-commercial lender; e.g., a relative or friend. The borrower/beneficiary and the lender of the funds complete these statements. SSA requires information from Forms SSA-2854 and SSA-2855 to determine whether the proceeds from the transaction are income to the borrower. If the transaction constitutes a bona fide loan, the proceeds are not income to the borrower. Form SSA-2855 (Statement of Funds You Received) requests information from the SSI applicant/recipient by personal interview. Form SSA-2854 (Statement of Funds You Provided to Another) requests information by mail from the other party to the transaction. The respondents are SSI recipients who informally borrow money and those persons who lend the funds.

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

Number of Respondents: 40,000.

Frequency of Response: 1.

Average Burden per Response: 10 minutes.

Estimated Annual Burden: 6,667 hours.

6. Self-Employment/Corporate Officer Questionnaire—20 CFR 404.435(e), 404.446—0960-0487. SSA uses Form SSA-4184 to develop earnings and corroborate the claimant's allegations of retirement when the claimant is self-employed or a corporate officer. SSA uses the information to determine an individual's OASDI benefit amount. The respondents are self-employed individuals or corporate officers who apply for OASDI benefits.

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

Number of Respondents: 50,000.

Frequency of Response: 1.

Average Burden per Response: 20 minutes.

Estimated Annual Burden: 16,667 hours.

Note:

This is a correction notice. SSA published this information collection as an extension on February 17, 2009 at 74 FR 7506. Since we are revising the Privacy Act Statement, this is now a revision.

7. Application for SSA Employee Testimony—20 CFR 403.100-155—0960-0619. SSA regulations at 20 CFR 403.100-155 establish policies and procedures for an individual, organization, or governmental entity to request official agency information, records, or testimony of an agency employee in a legal proceeding when the agency is not a party. The request, which must be in writing to the Commissioner, must fully set out the nature and relevance of the sought testimony. Respondents are individuals or entities who request testimony from SSA employees in a legal proceeding.

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

Number of Respondents: 100.

Frequency of Response: 1.

Average Burden per Response: 60 minutes.

Estimated Annual Burden: 100 hours.

8. Authorization for the Social Security Administration To Obtain Account Records from a Financial Institution and Request for Records (Medicare Low-Income Subsidy)—0960-0729. Under the aegis of the Medicare Modernization Act of 2003, Medicare beneficiaries can apply for a subsidy for the Medicare Prescription Drug Plan (Part D) program. In some cases, SSA will verify the details of applicants' accounts at financial institutions to determine if they are eligible for the subsidy. Form SSA-4640 gives SSA the authority to contact financial institutions about applicants' accounts. Financial institutions will also use the form to verify the information SSA requested. The respondents are applicants for the Medicare Part D program subsidy and financial institutions where applicants have accounts.

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

	Medicare part D subsidy applicants	Financial institutions	Totals
Number of Respondents	10,000	10,000	20,000.
Frequency of Response	1	1	1.
Average Burden per Response (minutes)	1 minute	4 minutes	5 minutes.
Estimated Annual Burden (hours)	167 hours	667 hours	834 hours.

Total Estimated Annual Burden: 834 hours.

9. Request To Pay Civil Monetary Penalty by Installment Agreement—20 CFR 498-0960-NEW. SSA uses Form SSA-640 to obtain the information necessary to determine a repayment rate for individuals who have a civil monetary penalty imposed on them for fraudulent conduct related to SSA-administered programs. SSA needs this financial information to ensure the repayment rate is in the best interest of both the individual and the agency. The respondents are recipients of Social Security benefits and non-entitled individuals who must pay a civil monetary penalty.

Type of Request: New information collection.

Number of Respondents: 400.

Frequency of Response: 1.

Average Burden per Response: 120 minutes.

Estimated Annual Burden: 800 hours.

Dated: April 17, 2009.

John Biles,

Reports Clearance Officer, Center for Reports Clearance, Social Security Administration.