E7-8804. 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 Pub. L. 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, faxed or e-mailed to the individuals at the addresses and 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, 1333 Annex Building, 6401 Security Blvd., Baltimore, MD 21235,Fax: [phone]. E-mail address: [e-mail].

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. Representative Payee Evaluation Report—20 CFR 404.2065 & 416.665—0960-0069. Sections 205(j) and 1631(a)(2) of the Social Security Act provide that a representative payee may be appointed to receive benefits on behalf of an individual entitled to Title II and/or Title XVI benefits when that individual is unable to manage or direct the management of those funds by themselves. The representative payee is required to report to SSA at least once per year on how those funds received have been used or conserved. When a representative payee fails to adequately report to SSA as required, SSA will conduct a face-to-face interview with the payee to complete an SSA-624, Representative Payee Evaluation Report, in order to determine the continued suitability of the representative payee to serve as a payee. The respondents are individuals and organizations who act as representative payees for Title II and Title XVI benefits who fail to comply with SSA's statutory annual reporting requirement.

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

Number of Respondents: 252,000.

Frequency of Response: 1.

Average Burden per Response: 30 minutes.

Estimated Annual Burden: 126,000 hours.

2. Request for Change in Time/Place of Disability Hearing—20 CFR 404.914(c)(2) and 416.1414(c)(2)—0960-0348. The information on Form SSA-769 is used by SSA and the State Disability Determination Services (DDS) to provide claimants with a structured format to exercise their right to request a change in time or place of a scheduled disability hearing. The information will be used as a basis for granting or denying requests for changes and for rescheduling disability hearings. Respondents are claimants who wish to request a change in the time and/or place of their hearing.

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

Number of Respondents: 7,483.

Frequency of Response: 1.

Average Burden Per Response: 8 minutes.

Estimated Annual Burden: 998 hours.

3. Agency/Employer Government Pension Offset Questionnaire—20 CFR 404.408(a)—0960-0470. The information collected by form SSA-4163 will provide SSA with accurate information from the agency paying the pension, for purposes of applying the pension-offset provision. The form will be used only when (1) the claimant does not have the information and (2) the pension-paying agency has not cooperated with the claimant. Respondents are Federal and State Government agencies which have information needed by SSA to determine if the GPO applies and the amount of offset.

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

Number of Respondents: 1000.

Frequency of Response: 1.

Average Burden Per Response: 3 minutes.

Estimated Annual Burden: 50 hours.

4. Child Care Dropout Questionnaire—20 CFR 404.211(e)(4)—0960-0474. Information collected on this form is ed by SSA to determine if an individual qualifies for a child care exclusion in computing the individual's disability benefit amount. Respondents are applicants for disability benefits.

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

Number of Respondents: 2000.

Frequency of Response: 1.

Average Burden Per Response: 5 minutes.

Estimated Annual Burden: 167 hours.

5. Statement for Determining Continuing Eligibility for Supplemental Security Income Payments—Adult, Form SSA-3988; Statement for Determining Continuing Eligibility for Supplemental Security Income Payments—Child, Form SSA-3989—20 CFR Subpart B—416.204—0960-0643.

Forms SSA-3988 and SSA-3989 will be used to determine whether SSI recipients have met and continue to meet all statutory and regulatory non-medical requirements for Supplemental Security Income eligibility, and whether they have been and are still receiving the correct payment amount. The SSA-3988 and SSA-3989 are designed as self-help forms that will be mailed to recipients or to their representative payees for completion and return to SSA. The respondents are recipients of SSI payments or their representatives.

Type of Request: Revisions to an existing OMB information collection.

Collection instrument	Respondents	Frequency of response	Average burden per response	Estimated annual burden (hours)
SSA-3988	30,000	1	26 min.	13,000
SSA-3989	30,000	1	26 min.	13,000
Totals	60,000			26,000

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. Treating Physician Consultative Examination Interest Form—20 CFR 404.1519g-i—0960-NEW. The individual's treating physician (TP) is the preferred source to perform a consultative examination (CE). SSA uses the SSA-84 to ascertain whether the TP is interested in performing the CE. This form is sent to the claimant's treating physician along with the medical evidence of record request letter. If the treating physician is interested in performing the CE, he or she indicates interest by completing the SSA-84 and returning it to SSA. If the form is not returned, SSA assumes that the TP is not interested in performing the CE. Respondents are the claimants' treating physicians.

Type of Request: Collection in Use Without an OMB Number.

Number of Respondents: 168.

Frequency of Response: 1.

Average Burden Per Response: 5 minutes.

Estimated Annual Burden: 14 hours.

2. Application for Child's Insurance Benefits—20 CFR 404.350-404.368, 404.603, & 416.350—0960-0010. SSA uses the information collected by the SSA-4-BK to entitle children of living and deceased workers to monthly Social Security payments. Respondents are guardians completing the form on behalf of the children of living or deceased workers, or the children of living or deceased workers.

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

Number of Respondents: 1,740,000.

Estimated Annual Burden: 344,141 hours.

Type of request	Number of respondents	Frequency per response	Average burden per response (minutes)	Estimated annual burden
Life Claims	46,250	1	10	7,708
Life Claims—MCS	439,375	1	10	73,229
Life Claims—Signature Proxy	439,375	1	9	65,906
Death Claims	40,750	1	15	10,188
Death Claims—MCS	387,125	1	15	96,781
Death Claims—Signature Proxy	387,125	1	14	90,329
Totals	1,740,000			344,141

3. Work History Report—20 CFR 404.1512 and 416.912— 0960-0578. The information collected by form SSA-3369 is needed to determine disability by the State DDS. The information will be used to document an individual's past work history. The respondents are applicants for SSI disability payments and Social Security disability benefits.

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

Number of Respondents: 1,000,000.

Frequency of Response: 1.

Average Burden Per Response: 30 minutes.

Estimated Annual Burden: 500,000 hours.

4. Beneficiary Interview and Auditor's Observations Form—0960-0630. The information collected through the Beneficiary Interview and Auditor's Observation Form, SSA-322, will be used by SSA's Office of the Inspector General to interview beneficiaries and/or their payees to determine whether representative payees are complying with their duties and responsibilities under SSA's regulations at 20 CFR 404.2035 and 416.635. Respondents to this collection will be randomly selected SSI recipients and Social Security beneficiaries who have representative payees.

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

Number of Respondents: 2,550.

Frequency of Response: 1.

Average Burden Per Response: 15 minutes.

Estimated Annual Burden: 638 hours.

5. Report to U.S. SSA by Person Receiving Benefits for a Child or Adult Unable to Handle Funds; Report to U.S. SSA—0960-0049. SSA needs the information on Form SSA-7161-OCR-SM to monitor the performance of representative payees outside the U.S and the information on Form SSA-7162-OCR-SM to determine continuing entitlement to Social Security benefits and correct benefit amounts for beneficiaries outside the U.S. The respondents are individuals outside the U.S. who are receiving benefits either for someone else, or on their own behalf, under title II of the Social Security Act.

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

Form No.	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated annual burden (hours)
SSA-7161-OCR-SM	30,000	1	15	7,500
SSA-7162-OCR-SM	236,500	1	5	19,708
Totals	257,000			27,208

6. Real Property Current Market Value Estimate—0960-0471. The SSA-L2794 is used to obtain current market value estimates of real property owned by applicants for, or recipients of, SSI payments (or a person whose resources are deemed to such an individual). The value of an individual's resources, including non-home real property is one of the eligibility requirements for SSI payments. The respondents are individuals with knowledge of local real property values.

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

Number of Respondents: 5,438.

Frequency of Response: 1.

Average Burden Per Response: 20 minutes.

Estimated Annual Burden: 1,813 hours.

7. Requests for Self-Employment Information, Employee Information, Employer Information—20 CFR 422.120—0960-0508. SSA uses forms SSA-L2765, SSA-L3365 and SSA-L4002 to request correct information when an employer, employee or self-employed person reports an individual's earnings without a Social Security Number (SSN) or with an incorrect name or SSN. The respondents are employers, employees or self-employed individuals who are requested to furnish additional identifying information.

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

Form No.	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated annual burden (hours)
SSA-L2765	15,400	1	10	2,567
SSA-L3365	173,100	1	10	28,850
SSA-L4002	656,000	1	10	109,333
Total	844,500			140,750

8. Questionnaire for Children Claiming SSI Benefits—0960-0499. The information collected on form SSA-3881-BK is used by SSA to evaluate disability in children who are appealing an unfavorable disability decision or whose continuing disability is being reviewed. The form requests the names and addresses of non-medical sources such as schools, counselors, agencies, organizations or therapists who would have information about a child's functioning. The respondents are children or their representatives who are appealing an unfavorable decision on their claim or whose continuing disability is being reviewed.

Type of Request: Extension of OMB-approved collection.

Number of Respondents: 253,000.

Frequency of Response: 1.

Average Burden Per Response: 30 minutes.

Estimated Annual Burden: 126,500 hours.

Dated: May 2, 2007.

Elizabeth A. Davidson,

Reports Clearance Officer, Social Security Administration.