2015-12454. 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 of OMB-approved information collections, and reinstatements of previously 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-2015-0029].

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 July 21, 2015. Individuals can obtain copies of the collection instruments by writing to the above email address.

1. Statement of Funds You Provided to Another and Statement of Funds You Received—20 CFR 404.1520(b), 404.1571-404.1576, 404.1584-404.1593 and 416.971-416.976—0960-0059. SSA uses Form SSA-821-BK to collect recipient employment information to determine whether recipients worked after becoming disabled and, if so, whether the work is substantial gainful activity. SSA's field offices use Form SSA-821-BK to obtain work information during the initial claims process, the continuing disability review process, and for Supplemental Security Income (SSI) claims involving work issues. SSA's processing centers and the Office of Disability and International Operations use the form to obtain post-adjudicative work issue from recipients. SSA reviews and evaluates the data to determine if the applicant or recipient meets the disability requirements of the law. The respondents are applicants and recipients of Title II Social Security and SSI disability payments.

Type of Request: Reinstatement with change of a previous OMB-approved information collection.

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-821-BK	300,000	1	30	150,000

2. Coverage of Employees of State and Local Governments—20 CFR 404, Subpart M—0960-0425. The Code of Federal Regulations at 20 CFR 404, Subpart M, prescribes the rules for States submitting reports of deposits and recordkeeping to SSA. States (and interstate instrumentalities) are required to provide wage and deposit contribution information for pre-1987 periods. Not all states have completely satisfied their pending wage report and contribution liability with SSA for pre-1987 tax years. These regulations are needed until all pending items with all states are closed out, and to provide for collection of this information in the future, if necessary. The respondents are State and local governments or interstate instrumentalities.

Type of Request: Reinstatement without change of a previously approved collection.

Regulation section	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
404.1204 (a) & (b)	52	1	30	26
404.1215	52	1	60	52
404.1216 (a) & (b)	52	1	60	52
Total	156			130

3. Credit Card Payment Form—0960-0648. SSA uses Form SSA-1414 to process: (1) Credit card payments from former employees and vendors with outstanding debts to the agency; (2) advance payments for reimbursable agreements; and (3) credit card payments for all Freedom of Information Act (FOIA) requests requiring payment. The respondents are former employees and vendors who have outstanding debts to the agency, entities who have reimbursable agreements with SSA, and individuals who request information through FOIA.

Type of Request: Reinstatement without change of a previous OMB-approved information collection.

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-1414	6,000	1	2	200

4. Social Security Administration Health IT Partner Program Assessment—Participating Facilities and Available Content Form—20 CFR 404.1614, 416.1014, 24 CFR 495.300-495.370—0960-0798. The Health Information Technology for Economic and Clinical Health (HITECH) Act promotes the adoption and meaningful use of health information technology (IT), particularly in the context of working with government agencies. Similarly, section 3004 of the Public Health Service Act requires health care providers or health insurance issuers with government contracts to implement, acquire, or upgrade their health IT systems and products to meet adopted standards and implementation specifications. To support expansion of SSA's health IT initiative as defined under HITECH, SSA developed Form SSA-680, the Health IT Partner Program Assessment—Participating Facilities and Available Content Form. The SSA-680 allows healthcare providers to provide the information SSA needs to determine their ability to exchange health information with us electronically. We evaluate potential partners (i.e., healthcare providers and organizations) on (1) the accessibility of health information they possess, and (2) the content value of their electronic health records' systems for our disability adjudication processes. SSA reviews the completeness of organizations' SSA-680 responses as one part of our careful analysis of their readiness to enter into a health IT partnership with us. The respondents are healthcare providers and organizations exchanging information with the agency.

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

Modality of completion	Number of respondents	Frequency of response	Average burden per response (hours)	Estimated total annual burden (hours)
SSA-680	30	1	5	150

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 22, 2015. Individuals can obtain copies of the OMB clearance packages by writing to [e-mail].

1. Application for Supplemental Security Income—20 CFR 416.305-416.335, Subpart C—0960-0444. SSA uses Form SSA-8001-BK to determine an applicant's eligibility for SSI and SSI payment amounts. SSA employees also collect this information during interviews with members of the public who wish to file for SSI. SSA uses the information for two purposes: (1) Formally deny SSI for non-medical reasons when information the applicant provides results in ineligibility; or (2) establish a disability claim, but defer the complete development of non-medical issues until SSA approves the disability. The respondents are applicants for SSI.

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)
MSSICS/Signature Proxy	1,195,521	1	20	398,507
Non-MSSICS (Paper)	140,145	1	20	46,715
Totals	1,335,666			445,222

2. Statement of Reclamation Action—31 CFR 210—0960-0734. Regulations governing the Federal Government Participation in the Automated Clearing House (1) allow SSA to send Social Security payments to Canada, and (2) mandate the reclamation of funds paid erroneously to a Canadian bank or financial institution after the death of a Social Security beneficiary. SSA uses Form SSA-1713, Notice of Reclamation Action, to determine if, how, and when the Canadian bank or financial institution is going to return erroneous payments after the death of a Social Security beneficiary who elected to have payments sent to Canada. Form SSA-1712 (or SSA-1712 CN), Notice of Reclamation-Canada Payment Made in the United States, is the cover sheet SSA prepares to request return of the payment. The respondents are Canadian banks and financial institutions who erroneously received Social Security 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-1713	15	1	5	1

Dated: May 19, 2015.

Faye I. Lipsky,

Reports Clearance Officer, Social Security Administration.