E6-4913. 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. Application for Special Age 72-or-Over Monthly Payments—20 CFR 404.380-404.384—0960-0096. Form SSA-19-F6 collects the information needed to determine whether a claimant can qualify for Special Age 72 payments. Eligibility requirements will be evaluated based on the data collected on this form. The respondents are individuals who reached age 72 before 1972.

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

Number of Respondents: 10.

Frequency of Response: 1.

Average Burden per Response: 10 minutes.

Estimated Annual Burden: 2 hours.

2. Medical or Psychological Review of Childhood Disability Evaluation Form (SSA-538)—20 CFR 416.1040, 416.1043, 416.1045, 416.924(g)—0960-0675. Form SSA-536 is used by SSA medical or psychological consultants to document their review and assessment of the Childhood Disability Evaluation Form, SSA-538, prepared by State DDS employees. A childhood disability evaluation is required in each SSI childhood disability case that is reviewed. The respondents are 256 SSA medical and psychological consultants.

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

Number of Responses: 17,000.

Frequency of Response: 1.

Average Burden Per Response: 12 minutes.

Estimated Annual Burden: 3,400 hours.

3. Claimant's Medication—20 CFR 404.1512, 416.912—0960-0289. The HA-4632, completed by applicants for disability benefits, provides an updated list of medications used by the claimant. This enables the Administrative Law Judge hearing the case to fully inquire into the medical treatment the claimant is receiving and the effect of medications on the claimant's impairments and functional capacity. The respondents are applicants for Old Age, Survivors and Disability Insurance (OASDI) benefits, and/or Supplemental Security income (SSI) payments.

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

Number of Respondents: 171,939.

Frequency of Response: 1.

Average Burden Per Response: 15 minutes.

Estimated Annual Burden: 42,985 hours.

4. Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records (Medicare Low-Income Subsidy)—0960-NEW. 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 need to verify the details of applicants' accounts at financial institutions to determine if they are eligible for the subsidy. Form SSA-4640 will give SSA the authority to contact financial institutions about beneficiaries' accounts. It will also be used by financial institutions to verify the information requested by SSA. The respondents are applicants for the Medicare Part D program subsidy and financial institutions where applicants have accounts.

Type of Request: New information request.

	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	4	5.
Estimated Annual Burden (hours)	167	667	834.

Total Estimated Annual Burden: 834 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. Claimant's Recent Medical Treatment—20 CFR 404.1512 & 416.912—0960-0292. The information collected on Form HA-4631 is used to facilitate processing an applicant's OASDI (Title II) and/or SSI (Title XVI) claim. The form elicits from the claimant an updated list of medical treatment. This enables the Administrative Law Judge hearing the case to fully inquire into past and current medical treatment the claimant received/receives and the effect on the claimant's physical and mental status. The respondents are applicants for OASDI benefits and/or SSI payments.

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

Number of Respondents: 320,000.

Frequency of Response: 1.

Average Burden per Response: 10 minutes.

Estimated Annual Burden: 53,333 hours.

2. 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 in situations where the SSI recipient alleges that he or she borrowed funds informally from a non-commercial lender, e.g., a relative or a friend. The statements are required to determine whether the proceeds from the transaction are income to the borrower. If the transaction constitutes a bona fide loan, then the proceeds are not income to the borrower. The respondents are the borrower/recipient and the lender of the funds.

Type of Request: Extension 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.

3. Quickstart Enrollment—31 CFR 209 and 210—0960-0564. Social Security beneficiaries and SSI recipients can enroll for direct deposit/electronic funds transfer through their financial institutions (FIs) using an automated enrollment process. SSA uses the information to facilitate electronic transmission of data for direct deposit of funds to a payee's account. The respondents are Social Security beneficiaries and SSI recipients requesting direct deposit to their financial institutions.

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

Number of Respondents: 3,950,000.

Frequency of Response: 1.

Average Burden Per Response: 3 minutes.

Estimated Annual Burden: 197,500 hours.

4. Certificate of Election for Reduced Spouse's Benefits—20 CFR 404.421—0960-0398. SSA uses the information collected on Form SSA-25 to pay a qualified spouse who elects to receive a reduced Social Security benefit. Reduced benefits are not payable to an already entitled spouse, at least age 62 but under full retirement age, who no longer has a child in care, unless the spouse elects to receive reduced benefits. The respondents are entitled spouses seeking reduced Social Security benefits.

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

Number of Respondents: 30,000.

Frequency of Response: 1.

Average Burden Per Response: 2 minutes.

Estimated Annual Burden: 1,000 hours.

5. Voluntary Customer Satisfaction Surveys in Accordance with E.O. 12862 for the Social Security Administration—0960-0526. Under the auspices of E.O. 12862, Setting Customer Service Standards, SSA conducts multiple customer satisfaction surveys each year. These voluntary customer satisfaction assessments include paper, Internet, and telephone surveys; mailed questionnaires; focus groups; and customer comment cards. The purpose of these surveys is to assess customer satisfaction with the timeliness, appropriateness, access, and overall quality of the services SSA provides. The respondents are direct recipients of SSA services and professionals and other individuals who work on behalf of SSA beneficiaries.

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

	Fiscal year 2006	Fiscal year 2007	Fiscal year 2008
Number of Respondents	1,352,181	1,356,001	1,357,851.
Frequency of Response	1	1	1.
Range of Response Times	Varies (5 minutes to 11/2 hours)	Varies (5 minutes to 11/2 hours)	Varies (5 minutes to 11/2 hours).
Estimated Annual Burden	119,646	120,993	121,191.

Note:

Please note that the figures above differ slightly from those published in the 60-day advance Notice. The reason for this difference is that SSA obtained updated burden data since publishing the 60-day Federal Register Notice.

Dated: March 30, 2006.

Elizabeth A. Davidson,

Reports Clearance Officer, Social Security Administration.