2015-12671. 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 extensions 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 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 27, 2015. Individuals can obtain copies of the collection instruments by writing to the above email address.

1. Statement of Employer—20 CFR 404.801-404.803—0960-0030. When workers report they were paid wages but cannot provide proof of those earnings, and the wages do not appear in SSA's records of earnings, SSA uses Form SSA-7011-F4 to document the alleged wages. Specifically, the agency uses the form to resolve discrepancies in the individual's Social Security earnings record and to process claims for Social Security benefits. We only send Form SSA-7011-F4 to employers if we are unable able to locate the earnings information within our own records. The respondents are employers who can verify wage allegations made by wage earners.

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-7011-F4	500	1	20	167

2. Function Report Adult-Third Party—20 CFR 404.1512 & 416.912—0960-0635. Individuals receiving or applying for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) provide SSA with medical evidence and other proof SSA requires to prove their disability. SSA, and Disability Determination Services (DDS) on our behalf, collect this information using Form SSA-3380-BK. We use the information to document how claimant's disabilities affect their ability to function, and to determine eligibility for SSI and SSDI claims. The respondents are third parties familiar with the functional limitations (or lack thereof) of claimants who apply for SSI and SSDI 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-3380-BK	780,000	1	61	793,000

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 26, 2015. Individuals can obtain copies of the OMB clearance packages by writing to [e-mail].

1. Application for Parent's Insurance Benefits—20 CFR 404.370-404.374, 20 CFR 404.601-404.603—0960-0012. Section 202(h) of the Social Security Act establishes the conditions of eligibility a claimant must meet to receive monthly benefits as a parent of a deceased worker. SSA uses information from Form SSA-7-F6 to determine if the claimant meets the eligibility and application criteria. The respondents are applicants for, and recipients of, Social Security Old Age, Survivors, and Disability Insurance (OASDI).

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)
Modernized Claims System (MCS)	153	1	15	38
MCS/Signature Proxy	158	1	14	37
Paper Form	4	1	15	1
Total	315			76

2. Request for Withdrawal of Application—20 CFR 404.640—0960-0015. Form SSA-521 documents the information SSA needs to process the withdrawal of an application for benefits. A paper SSA-521 is our preferred instrument for executing a withdrawal request; however, any written request for withdrawal signed by the claimant or a proper applicant on the claimant's behalf will suffice. Individuals who wish to withdraw their applications for benefits complete Form SSA-521, or sign the completed form for each request to withdraw. SSA uses the information from the SSA-521 to process the request for withdrawal. The respondents are applicants for Retirement, Survivors, Disability, and Health Insurance 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-521	39,000	1	5	3,250

3. Claimant's Medication—20 CFR 404.1512, 416.912—0960-0289. In cases where claimants request a hearing after denial of their disability claim for Social Security, SSA uses Form HA-4632 to request information from the claimant regarding the medications they use. This information helps the administrative law judge overseeing the case to fully investigate: (1) The claimant's medical treatment and (2) the effects of the medications on the claimant's medical impairments and functional capacity. The respondents are applicants (or their representatives) for OASDI benefits or SSI payments who request a hearing to contest an agency denial of their claim.

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)
HA-4632 (paper)	20,000	1	15	5,000
Electronic Records Express	180,000	1	15	45,000
Total	200,000			50,000

4. Permanent Residence in the United States Under Color of Law (PRUCOL)—20 CFR 416.1615 and 416.1618—0960-0451. As per 20 CFR 416.1415 and 416.1618 of the Code of Federal Regulations, SSA requires claimants or recipients to submit evidence of their alien status when they apply for SSI payments, and periodically thereafter as part of the eligibility determination process for SSI. When SSA cannot verify evidence of alien status through the regular claimant interview process, SSA verifies the validity of the evidence of PRUCOL for grandfathered nonqualified aliens with the Department of Homeland Security (DHS), and determines if the individual qualifies for PRUCOL status based on the DHS response. SSA does not maintain any forms or applications for respondents to use, rather, the regulations listed in 20 CFR 416.1615 and 416.1618 specify the information respondents need to submit to SSA to show evidence of PRUCOL. Without this information, SSA is unable to determine whether the PRUCOL individual is eligible for SSI payments. Respondents are qualified and unqualified aliens who apply for SSI payments under PRUCOL.

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)
Personal or Telephone Interview	1,049	1	5	87

5. Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records (Medicare)—0960-0729. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) established the Medicare Part D program for voluntary prescription drug coverage of premium, deductible, and copayment costs for individuals with limited income and resources. The MMA mandates that the Government provide subsidies for those individuals who qualify for the program, and who meet eligibility criteria for help with premium, deductible, or co-payment costs. SSA uses the SSA-4640, Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records (Medicare) to determine if subsidy applicants or recipients qualify, or continue to qualify, for the subsidy. SSA uses Form SSA-4640 to:

(1) Obtain the individual's consent to verify balances of financial institution (FI) accounts; and (2) obtain verification of such balances from the FI. Respondents are Medicare Part D program subsidy applicants or claimants, and their financial institutions.

This is a correction notice. SSA published this information collection as a revision on March 9, 2015 at 80 FR 12542. 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)
Medicare Part D Subsidy Applicants	5,000	1	1	83
Financial Institutions	5,000	1	4	333
Total	10,000			416

Dated: May 20, 2015.

Faye I. Lipsky,

Reports Clearance Officer, Social Security Administration.