03-18906. 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 effective October 1, 1995, The Paperwork Reduction Act of 1995. The information collection packages that may be included in this notice are for new 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, New Executive Office Building, Room 10235, 725 17th St., NW., Washington, DC 20503, Fax [phone].

(SSA)

Social Security Administration, DCFAM, Attn: Reports Clearance Officer, 1338 Annex, 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, Subpart D, 404.380-.384—0960-0096. Form SSA-19-F6 is needed to determine if an individual is entitled to Special Age 72 payments. Eligibility requirements will be evaluated based on the data collected on this form. The respondents are individuals who attained 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: 20 minutes.

Estimated Annual Burden: 3 hours.

2. Statement of Self-Employment Income, CFR Subpart B, 404.101 and Subpart K, 404.1096—0960-0046. The information collected on Form SSA-766 is used to determine if the individual will have at least the minimum amount of self-employment income needed for one or more quarters of coverage in the current year. Additional quarters of coverage may be credited on the basis of the information obtained, and benefit payments may be expedited where there are sufficient quarters of coverage to give the individual insured status. The respondents are self-employed persons applying for Social Security benefits.

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

Number of Respondents: 5,000.

Frequency of Response: 1.

Average Burden Per Response: 5 minutes.

Estimated Annual Burden: 417 hours.

3. Childhood Disability Evaluation Form—20 CFR 416.924-0960-0568. SSA and State Disability Determination Services (DDS) use the information collected on Form SSA-538 to record medical and functional findings regarding the severity of impairments of the children who claim SSI benefits based on disability. The form is used for initial determinations of eligibility, in appeals, and in initial continuing disability reviews. The respondents are employees of DDS responsible for these determinations.

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

Number of Respondents: 750,000.

Frequency of Response: 1.

Average Burden Per Response: 25 minutes.

Estimated Annual Burden: 312,500 hours.

4. Subpart T—State Supplementation Provisions—20 CFR 416.2095-2099—0960-0240. Section 1618 of the Social Security Act contains pass-along provisions of the Social Security Amendments. These provisions require States that supplement the Federal SSI benefits pass along Federal cost-of-living increases to the individuals who are eligible for State Supplementary benefit payments. If the State fails to keep payments at the required level, it becomes ineligible for Medicaid reimbursement under Title XIX of the Social Security Act. Regulations at 20 CFR 416.2099 require the States to report mandatory minimum and optional supplementary payment data to SSA. The information is used to determine compliance with the law and regulations. The respondents are States that supplement Federal SSI payments.

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

Number of Respondents: 26.

Frequency of Response: 15 states report quarterly; 11 states report annually.

Average Burden per Response: 1 hour.

Estimated Annual Burden: 71.

5. Representative Payee Report-Special Veterans Benefits Form—0960-0621. SSA needs the information collected on form SSA-2001 to determine whether payments certified to the representative payee have been used properly and whether the representative payee demonstrates concern for the beneficiary's best interest. The form will be completed annually by representative payees receiving Special Veterans Benefit payments on behalf of beneficiaries who are outside of the United States. It will also be required when SSA has reason to believe a representative payee could be misusing the payments. The respondents are representative payees for beneficiaries who are receiving Special Veterans Benefits.

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

Number of Respondents: 100.

Frequency of Response: 1.

Average Burden Per Response: 10 minutes.

Estimated Annual Burden: 17 hours.

6. You Can Make Your Payment by Credit Card—0960-0462. SSA will use the information on Forms SSA-4588 and SSA-4589 to update the individual's social security record to reflect that a payment has been made on their overpayment and to effectuate payment through the appropriate credit card company. The respondents are Title II (Old-Age, Survivors and Disability Insurance) and Title XVI (Supplemental Security Income) debtors; and citizens requesting material through SSA.

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

Number of Respondents: 19,000.

Frequency of Response: 1.

Average Burden Per Response: 5 minutes.

Estimated Annual Burden: 1,583 hours.

II. The information collection listed below has 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 package by calling the SSA Reports Clearance Officer at 410-965-0454, or by writing to the address listed above.

1. Certification by Religious Group—20 CFR, Subpart K, 404.1075—0960-0093. The data collected on Form SSA-1458 will be used to determine if a religious group meets the qualifications set out in section 1402(g) of the Internal Revenue Code, which permits its members to be exempt from the payment of self-employment taxes. The respondents are spokespersons for a religious group or sect.

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

Number of Respondents: 180.

Frequency of Response: 1.

Average Burden Per Response: 15 minutes.

Estimated Annual Burden: 45 hours.

2. Statement of Care and Responsibility for Beneficiary—20 CFR, Subpart U, 404.2020-.2025 & Subpart F, 416.620-.625-0960-0109. Form SSA-788 is used to obtain information from the beneficiary's custodian about the representative payee applicant's concern and responsibility for the beneficiary. The respondents are individuals who have custody of a beneficiary, where someone else has filed to be the beneficiary's payee.

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

Number of Respondents: 130,000.

Frequency of Response: 1.

Average Burden Per Response: 10 minutes.

Estimated Annual Burden: 21,667.

3. Request for Reconsideration—Disability Cessation—20 CFR, Subpart J, 404.909 & Subpart N, 416.1409-0960-0349. Form SSA-789 is used by SSA to schedule disability hearings and to develop additional evidence/information for claimants whose disability is found to have ceased, not to have existed, or to no longer be disabling. The information will also be used to determine if an interpreter is needed for the disability hearing. The respondents are claimants under Title II & XVI of the Social Security Act who wish to request reconsideration of disability cessation.

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

Number of Respondents: 49,000.

Frequency of Response: 1.

Average Burden Per Response: 10-13.5 minutes.

Estimated Annual Burden: 10,045 hours.

4. Psychiatric Review Technique—20 CFR, Subpart P, 404.1520(a) Subpart I, 416.920(a)-0960-0413. Form SSA-2506-BK assists the Disability Determination Services (DDS) in evaluating mental impairments by helping to (1) identify the need for additional evidence for impairment severity; (2) consider aspects of the mental impairment relevant to the individual's ability to perform work-related mental functions; and (3) organize and present the findings in a clear, concise and consistent manner. The respondents are 54 State DDSs administering Title II and title XVI disability programs.

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

Number of Responses: 1,253,703.

Frequency of Response: 1.

Average Burden Per Response: 15 minutes.

Estimated Annual Burden: 313,426 hours.

5. Request for Reconsideration—20 CFR, Subpart J, 404.907-.921 and Subpart N, 416.1407-.1421-0960-0622. The information collected on Form SSA-561 is used by SSA to document and initiate the reconsideration process for determining entitlement to Social Security benefits (Title II), Supplemental Security Income payments (Title XVI), and Special Veterans benefits (Title VIII). The respondents are individuals filing for such reconsideration.

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

Number of Respondents: 1,455,000.

Frequency of Response: 1.

Average Burden Per Response: 8 minutes.

Estimated Annual Burden: 194,000 hours.

6. Individuals or Agents Seeking Information or Testimony in non-Social Security Administration Cases—20 CFR 403.120-0960-0619. 20 CFR 403.120 establishes a procedure whereby an individual, organization or governmental entity may request testimony of an agency employee in a legal proceeding to which the agency is not a party. The request, which must be in writing to the Commissioner, must fully explain the nature and the relevance of the sought testimony and include the time, date, and place where the testimony will be given. Respondents are individuals or their representatives who require testimony from Social Security Administration employees in a legal proceeding to which the Social Security Administration is not a party.

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

Number of Respondents: 40.

Frequency of Response: 1.

Average Burden Per Response: 60 minutes.

Estimated Annual Burden: 40.

7. Medical Consultant's Review of Physical Functional Capacity Assessment—20 CFR 404.1520(a), 20 CFR 404.1640, 20 CFR 404.1645, 20 CFR 404.1643, and 20 CFR 416.920(a) —OMB #0960-NEW. The SSA-392 is used by the Social Security Administration's regional review component to facilitate the medical consultant's review of the Physical Residual Functional Capacity Form, the SSA-4734. The SSA-392 records the reviewing medical consultant's assessment of the SSA-4734 that was prepared by the adjudicating component. The SSA-392 is required for each SSA-4734 form completed. The respondents are the medical/psychological consultants responsible for reviewing the SSA-4734.

Type of Request: Request for approval of new collection.

Number of Respondents: 256.

Frequency of Response: 359.

Average Burden Per Response: 12 minutes.

Estimated Annual Burden: 18,380 hours.

8. Medical Consultant's Review of Mental/Functional Capacity Assessment Form, SSA 392 SUP.—20 CFR 404.1640, 20 CFR 404.1645, 20 CFR 404.1643, 20 CFR 404.1520(a) and 20 CFR 416.920(a)—0960-NEW. Medical Consultant's Review of Mental Residual Functional Capacity Form, SSA-392 SUP, is used by the Social Security Administration's regional review component to facilitate the medical/psychological consultant's review of the Mental Residual Functional Capacity Form or SSA-4734-SUP. The form records the reviewing medical/psychological consultant's assessment of the SSA-4734-SUP prepared by the adjudicating component and whether the reviewer agrees or disagrees with the manner in which the SSA-4734-SUP was completed. The SSA-392-SUP is required for each SSA-4734-SUP form completed. The respondents are the medical/psychological consultants responsible for reviewing the SSA-4734-SUP.

Type of Request: Request for approval of new collection.

Number of Respondents: 256.

Frequency of Response: 359.

Average Burden Per Response: 12 minutes.

Estimated Annual Burden: 18,380.

9. Request for Withdrawal of Application—20 CFR 404.460—0960-0015. Request for Withdrawal of Application—0960-0015. Form SSA-521 is completed by the Social Security Administration (SSA) when an individual wishes to withdraw his or her application for Social Security benefits. The respondents are individuals who wish to withdraw their applications for benefits.

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

Number of Respondents: 100,000.

Frequency of Response: 1.

Average Burden Per Response: 5 minutes.

Estimated Annual Burden: 8,333 hours.

Dated: July 21, 2003.

Nicholas E. Tagliareni,

Acting Reports Clearance Officer, Social Security Administration.