2015-10057. 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, and one new information 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 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-2015-0015].

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 June 29, 2015. Individuals can obtain copies of the collection instruments by writing to the above email address.

1. Application for a Social Security Number Card, the Social Security Number Application Process (SSNAP), and Internet SSN Replacement Card (iSSNRC) Application—20 CFR 422.103-422.110—0960-0066. SSA collects information on the SS-5 (used in the United States) and SS-5-FS (used outside the United States) to issue original or replacement Social Security cards. SSA also enters the application data into the Social Security Number Application Process (SSNAP) when applicants request a new or replacement card via telephone or in person. In addition, hospitals collect the same information on SSA's behalf for newborn children through the Enumeration-at-Birth process. In this process, parents of newborns provide hospital birth registration clerks with information required to register these newborns. Hospitals send this information to State Bureaus of Vital Statistics (BVS), and they send the information to SSA's National Computer Center. SSA then uploads the data to the SSA mainframe along with all other enumeration data, and we assign the newborn a Social Security number (SSN) and issue a Social Security card. Respondents can also use these modalities to request a change in their SSN records. Additionally, the iSSNRC application will collect information similar to the paper SS-5 for no-change replacement SSN cards for adult U.S. citizens.

A new iSSNRC modality included in the current clearance will allow certain applicants for an SSN replacement card to apply by completing an internet application and submitting the required evidence online rather than completing a paper Form SS-5, Application for a Social Security Card.

The respondents for this collection are applicants for original and replacement Social Security cards, or individuals who wish to change information in their SSN records, who use any of the modalities described above.

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

Application scenario	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
Respondents who do not have to provide parents' SSNs	10,500,000	1	8.5	1,487,500
* Adult U.S. Citizens requesting a replacement card with no changes through new iSSNRC modality	1,500,000	1	5	125,000
Respondents whom we ask to provide parents' SSNs (when applying for original SSN cards for children under age 18)	400,000	1	9	60,000
Applicants age 12 or older who need to answer additional questions so SSA can determine whether we previously assigned an SSN	1,500,000	1	9.5	237,500
Applicants asking for a replacement SSN card beyond the new allowable limits (i.e., who must provide additional documentation to accompany the application)	900	1	60	900
Authorization to SSA to obtain personal information cover letter	500	1	15	125
Authorization to SSA to obtain personal information follow-up cover letter	500	1	15	125
Totals	13,901,900			1,911,150
* The total timeline for complete national coverage of the iSSNRC application is two years from the date of initial implementation and is dependent on the contractor enrolling each State into the network. By FY 2018, we would expect to issue about 1.5 million replacement cards annually via the iSSNRC application. However, the estimated volume could vary based on the date of implementation, when the contractor acquires States, and our marketing efforts to the public.

Cost Burden: The state BVSs incur costs of approximately $11 million for transmitting data to SSA's mainframe. However, SSA reimburses the states for these costs.

2. Third Party Liability Information Statement—42 CFR 433.136-433.139—0960-0323. To reduce Medicaid costs, Medicaid state agencies must identify third party insurers liable for medical care or services for Medicaid beneficiaries. Regulations at 42 CFR 433.136-433.139 require Medicaid state agencies to obtain this information on Medicaid applications and redeterminations as a condition of Medicaid eligibility. States may 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 Supplemental Security Income (SSI) eligibility in jurisdictions with such agreements are 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 Medicaid state agencies. The Medicaid state agencies use the information to bill 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 claimants 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-8012 Paper form	200	1	5	17
Modernized SSI Claims System (MSSICS)	51,381	1	5	4,282
Totals	51,581			4,299

3. Request for Deceased Individual's Social Security Record—20 CFR 402.130—0960-0665. When a member of the public requests an individual's Social Security record, SSA needs the name and address of the requestor as well as a description of the requested record to process the request. SSA uses the information the respondent provides on Form SSA-711, or via an Internet request through SSA's electronic Freedom of Information Act (eFOIA) Web site, to (1) verify the wage earner is deceased and (2) access the correct Social Security record. Respondents are members of the public requesting deceased individuals' Social Security records.

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)
Internet Request through eFOIA	49,800	1	7	5,810
SSA-711 (paper)	200	1	7	23
Total	50,000			5,833

Cost Burden *: In addition, SSA charges fees to the respondent for this information. The following chart shows the fees per transaction based on the information the respondent provides on the SSA-711 (or in eFOIA):

Modality of completion	Information provided (or not provided)	Cost per transaction
SSA-711 (paper)	SSN of decedent is not provided	$29
SSA-711 (paper)	SSN of decedent is provided	$27
eFOIA (Internet)	SSN of decedent is not provided	$18

* As these costs are dependent on the respondent's provided information, we charge them on an as needed basis, and cannot provide a total annual estimate of the cost burden. We do not know whether the respondent provided the decedent's SSN until we manually review and process each SSA-711.

4. Function Report Adult—20 CFR 404.1512 & 416.912—0960-0681. Individuals receiving or applying for Social Security disability insurance (SSDI) or SSI must provide medical evidence and other proof SSA requires to prove their disability. SSA, and State disability determinations services on our behalf, collect the information using Form SSA-3373. We use the information to document how claimants' disabilities affect their ability to function, and to determine eligibility for SSI and SSDI claims. The respondents are Title II and Title XVI applicants (or current recipients undergoing redeterminations) for disability 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)
SSA-3373	2,085,721	1	61	2,120,483

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 June 1, 2015. Individuals can obtain copies of the OMB clearance packages by writing to [e-mail].

1. Data Exchange Request Form—20 CFR 401.100—0960-NEW. SSA maintains approximately 3,000 data exchange agreements and regularly receives new requests from Federal, State, local, and foreign governments, as well as private organizations, to share data electronically. SSA engages in various forms of data exchanges from Social Security number verifications to computer matches for benefit eligibility, depending on the requestor's business needs. Section 1106 of the Social Security Act requires we consider the requestor's legal authority to receive the data, our disclosure policies, systems' feasibility, systems' security, and costs before entering into a data exchange agreement. We will use Form SSA-157, Data Exchange Request Form, for this purpose. Requesting agencies, governments, or private organizations will use the form when voluntarily initiating a request for data exchange from SSA. Respondents are Federal, State, local, and foreign governments, as well as private organizations seeking to share data electronically with SSA.

This is a correction notice: SSA published the incorrect burden information for this collection at 80 FR 9499, on February 23, 2015. We are correcting this error here.

Type of Request: This is a new information collection request.

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-157	121	1	30	61

2. Statement of Self-Employment Income—20 CFR 404.101, 404.110, 404.1096(a)-(d)—0960-0046. To qualify for insured status and thus collect Social Security benefits, self-employed individuals must demonstrate they have earned the minimum amount of self-employment income (SEI) in a current year. SSA uses Form SSA-766, Statement of Self-Employment Income, to collect the information we need to determine if the individual will have at least the minimum amount of SEI needed for one or more quarters of coverage in the current year. Based on the information we obtain, we may credit additional quarters of coverage to give the individual insured status thus expediting benefit payments.

Respondents are self-employed individuals who may be eligible for Social Security benefits.

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-766	2,500	1	5	208

3. Request for Workers' Compensation/Public Disability Benefit Information—20 CFR 404.408(e)—0960-0098. Claimants for Social Security disability payments who are also receiving Worker's Compensation/Public Disability Benefits (WC/PDB) must notify SSA about their WC/PDB, so the agency can reduce claimants' Social Security disability payments accordingly. If claimants provide necessary evidence, such as a copy of their award notice, benefit check, etc., that is sufficient verification. In cases where claimants cannot provide such evidence, SSA uses Form SSA-1709. The entity paying the WC/PDB benefits, its agent (such as an insurance carrier), or an administering public agency complete this form. The respondents are Federal, State, and local agencies, insurance carriers, and public or private self-insured companies administering WC/PDB benefits to disability claimants.

This is a correction notice. SSA published this information collection as a revision on February 23, 2015 at 80 FR 9500. Since we are not revising the Privacy Act Statement, this is now an extension of an OMB-approved information collection.

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)
SSA-1709	120,000	1	15	30,000

Dated: April 27, 2015.

Faye I. Lipsky,

Reports Clearance Officer, Social Security Administration.