2018-16727. 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 a new information collection, extensions and revisions 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-2018-0044].

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 October 5, 2018. Individuals can obtain copies of the collection instruments by writing to the above email address.

1. Certificate of Support—20 CFR 404.370, 404.750, 404.408a—0960-0001. A parent of a deceased, fully insured worker may be entitled to Social Security Old-Age, Survivors, and Disability Insurance (OASDI) benefits based on the earnings record of the deceased worker under certain conditions. One of the conditions is the parent receives at least one-half support from the deceased worker. The one-half support requirement also applies to a spousal applicant in determining whether OASDI benefits are subject to Government Pension Offset (GPO). SSA uses Form SSA-760-F4 to determine if the parent of a deceased worker or a spouse applicant meets the one-half support requirement. Respondents are parents of deceased workers, and spouses who may meet the GPO exception.

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-760-F4	18,000	1	15	4,500

2. Application for Supplemental Security Income—20 CFR 416.207 and 416.305-416.335, Subpart C—0960-0229. The Supplemental Security Income (SSI) program provides aged, blind, and disabled individuals who have little or no income, with funds for food, clothing, and shelter. Individuals complete Form SSA-8000-BK to apply for SSI. SSA uses the information from Form SSA-8000-BK, and its electronic Intranet counterpart, the SSI Claims System, to: (1) Determine whether SSI claimants meet all statutory and regulatory eligibility requirements; and (2) calculate SSI payment amounts. The respondents are applicants for SSI or their representative payees.

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)
SSI Claims System	1,212,512	1	35	707,299
SSA-8000 (Paper Form)	20,941	1	41	14,310
Totals	1,233,453			721,609

3. Statement of Household Expenses and Contributions—20 CFR 416.1130-416.1148—0960-0456. SSA bases eligibility for SSI on the needs of the recipient. In part, we assess need by determining the amount of income a recipient receives. This income includes in-kind support and maintenance in the form of food and shelter owners provide. SSA uses Form SSA-8011-F3 to determine whether the claimant or recipient receives in-kind support and maintenance. This is necessary to determine: (1) The claimant's or recipient's eligibility for SSI, and (2) the SSI payment amount. SSA only uses this form in cases where SSA needs the householder's (head of household) corroboration of in-kind support and maintenance. The SSA-8011-F3 provides information, which could affect SSI eligibility and payment amount. The claim specialist collects the information on Form SSA-8011-F3 through telephone contact with the respondent, or through face-to-face interviews. The claims specialist records the information in our electronic SSI Claims System. When we use this procedure we do not use a paper Form SSA-8011-F3, and we do not need a wet signature, rather we require verbal attestation. However, when we use a paper form, we ensure the appropriate person, i.e., the householder signs the form, and then the claims specialist documents the information in the SSI Claims System; faxes the form into the appropriate electronic folder; and shreds form. Respondents are householders of homes in which an SSI applicant or recipient resides.

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-8011-F3 (Paper Version)	8,233	1	15	2,058
SSA-8011-F3 (SSI Claims System)	417,025	1	15	104,256
Total	425,258			106,314

4. Integrated Registration Services (IRES) System—20 CFR 401.45—0960-0626. The IRES System verifies the identity of individuals, businesses, organizations, entities, and government agencies seeking to use SSA's secured internet and telephone applications. Individuals need this verification to electronically request and exchange business data with SSA. Requestors provide SSA with the information needed to establish their identities. Once SSA verifies identity, the IRES system issues the requestor a user identification number and a password to conduct business with SSA. Respondents are employers; employees; third party submitters of wage data business entities providing taxpayer identification information; appointed representatives; representative payees; and data exchange partners conducting business in support of SSA programs.

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)
IRES Internet Registrations	611,296	1	5	50,941
IRES Internet Requestors	15,692,525	1	2	523,084
IRES CS (CSA) Registrations	20,621	1	11	3,781
Totals	16,324,442			577,806

5. Request for Reinstatement (Title II)—20 CFR 404.1592b-404.1592f—0960-0742. SSA allows certain previously entitled disability beneficiaries to request expedited reinstatement (EXR) of benefits under Title II of the Social Security Act (Act) when their medical condition no longer permits them to perform substantial gainful activity. SSA uses Form SSA-371 to obtain: (1) A signed statement from individuals requesting an EXR of their Title II disability benefits; and (2) proof the requestors meet the EXR requirements. SSA maintains the form in the disability folder of the applicant to demonstrate the requestors' awareness of the EXR requirements, and their choice to request EXR. Respondents are applicants for EXR of Title II disability 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-371	10,000	1	2	333

6. Important Information About Your Appeal, Waiver Rights, and Repayment Options—20 CFR 404.502-521—0960-0779. When SSA accidentally overpays beneficiaries, the agency informs them of the following rights: (1) The right to reconsideration of the overpayment determination; (2) the right to request a waiver of recovery and the automatic scheduling of a personal conference if SSA cannot approve a request for waiver; and (3) the availability of a different rate of withholding when SSA proposes the full withholding rate. SSA uses Form SSA-3105, Important Information About Your Appeal, Waiver Rights, and Repayment Options, to explain these rights to overpaid individuals and allow them to notify SSA of their decision(s) regarding these rights. The respondents are overpaid current, or former, beneficiaries requesting a waiver of recovery for the overpayment; reconsideration of the fact of the overpayment; or a lesser rate of withholding of the overpayment.

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-3105 Paper form	500,000	1	15	125,000
Debt Management System	200,000	1	15	50,000
Totals	700,000			175,000

II. SSA submitted the information collections below to OMB for clearance. Your comments regarding these 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 September 5, 2018. Individuals can obtain copies of the OMB clearance packages by writing to [e-mail].

1. Fee Agreement for Representation before the Social Security Administration—0960-NEW. Under the Act, SSA requires individuals who represent a claimant before the agency and want to receive a fee for their services to obtain SSA's authorization of the fee. One way to obtain the authorization is to submit the fee agreement. To facilitate this process, individuals can use Form SSA-1693. SSA uses the information from the SSA-1693 to review the request and authorize any fee to representatives who seek to charge and collect a fee from a claimant. The respondents are the representatives who help claimants through the application process.

Type of Request: Request for a new information collection.

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-1693	600,000	1	12	120,000

2. Request for Waiver of Overpayment Recovery and Request for Change in Overpayment Recovery Rate—20 CFR 404.502, 404.506-404.512, 416.550-416.558, and 416.570-416.571—0960-0037. When Social Security beneficiaries and SSI recipients receive an overpayment, they must return the extra money. These beneficiaries and recipients can use Form SSA-632-BK to request a waiver from repaying their overpayment. Beneficiaries and recipients can also use Form SSA-634 to request a change to the monthly recovery rate of their overpayment. The respondents must provide financial information to help the agency determine how much the overpaid person can afford to repay each month. Respondents are overpaid Social Security beneficiaries or SSI recipients who are requesting: (1) A waiver of recovery of an overpayment, or (2) a lesser rate of withholding.

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-632—Waiver of Overpayment (If completing entire paper form, including the AFI authorization)	400,000	1	120	800,000
Regional Application (New York Debt Management)	30,000	1	120	60,000
Internet Instructions	430,000	1	5	35,833
SSA-634—Requesting change in repayment rate (completing paper form)	100,000	1	45	75,000
Internet Instructions	100,000	1	5	8,333
Totals	1,060,000			979,166

3. Employment Relationship Questionnaire—20 CFR 404.1007—0960-0040. When SSA needs information to determine a worker's employment status for the purpose of maintaining a worker's earning records, the agency uses Form SSA-7160-F4 to determine the existence of an employer-employee relationship. We use the information to develop the employment relationship; specifically, to determine whether a beneficiary is self-employed or an employee. The respondents are individuals seeking to establish their status as employees, and their alleged employers.

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)
Individuals	8,000	1	25	3,333
Businesses	7,200	1	25	3,000
State/Local Government	800	1	25	333
Totals	16,000			6,666

4. State Supplementation Provisions: Agreement; Payments—20 CFR 416.2095-416.2098, and 20 CFR 416.2099—0960-0240. Section 1618 of the Act requires those states administering their own supplementary income payment program(s) to demonstrate compliance with the Act by passing Federal cost-of-living increases on to individuals who are eligible for state supplementary payments, and informing SSA of their compliance. In general, states report their supplementary payment information annually by the maintenance-of-payment levels method. However, SSA may ask them to report up to four times in a year by the total-expenditures method. Regardless of the method, the states confirm their compliance with the requirements, and provide any changes to their optional supplementary payment rates. SSA uses the information to determine each state's compliance or noncompliance with the pass-along requirements of the Act to determine eligibility for Medicaid reimbursement. If a state fails to keep payments at the required level, it becomes ineligible for Medicaid reimbursement under Title XIX of the Act. Respondents are state agencies administering supplemental programs.

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

Modality of completion	Number of responses	Frequency of response	Number of responses	Average burden per response (minutes)	Estimated total annual burden (hours)
Total Expenditures	7	4	28	60	28
Maintenance of Payment Levels	26	1	26	60	26
Total	33				54

5. Substitution of Party Upon Death of Claimant—20 CFR 404.957(c)(4) and 416.1457(c)(4)—0960-0288. An administrative law judge (ALJ) may dismiss a request for a hearing on a pending claim of a deceased individual for Social Security benefits or SSI payments. Individuals who believe the dismissal may adversely affect them may complete Form HA-539, which allows them to request to become a substitute party for the deceased claimant. The ALJs and the hearing office support staff use the information from the HA-539 to: (1) Maintain a written record of request; (2) establish the relationship of the requester to the deceased claimant; (3) determine the substituted individual's wishes regarding an oral hearing or decision on the record; and (4) admit the data into the claimant's official record as an exhibit. The respondents are individuals requesting to be substitute parties for a deceased claimant.

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-539	4,000	1	5	333

6. Claimant Statement about Loan of Food or Shelter; Statement about Food or Shelter Provided to Another—20 CFR 416.1130-416.1148—0960-0529. SSA bases an SSI claimant or recipient's eligibility on need, as measured by the amount of income an individual receives. Per our calculations, income includes other people providing in-kind support and maintenance in the form of food and shelter to SSI applicants or recipients. SSA uses Forms SSA-5062 and SSA-L5063 to obtain statements about food or shelter provided to SSI claimants or recipients. SSA uses this information to determine whether food or shelters are bona fide loans or income for SSI purposes. This determination may affect claimants' or recipients' eligibility for SSI as well as the amounts of their SSI payments. The respondents are claimants and recipients for SSI payments, and individuals who provide loans of food or shelter to them.

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-5062 Paper Form	30,632	1	10	5,105
SSA-L5063 Paper Form	30,632	1	10	5,105
SSA-5062 SSI Claims System	30,632	1	10	5,105
SSA-L5063 SSI Claims System	30,632	1	10	5,105
Total	122,528			20,420

7. Application for Circuit Court Law—20 CFR 404.985 & 416.1458—0960-0581. People claiming an acquiescence ruling (AR) would change SSA's prior determination or decision must submit a written readjudication request with specific information. SSA reviews the information in the requests to determine if the issues stated in the AR pertain to the claimant's case, and if the claimant is entitled to readjudication. If readjudication is appropriate, SSA considers the issues the AR covers. Any new determination or decision is subject to administrative or judicial review as specified in the regulations, and the claimants must provide information to request readjudication. Respondents are claimants for Social Security benefits and SSI payments who request readjudication.

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)
AR-based Readjudication Requests	10,000	1	17	2,833

8. Testimony by Employees and the Production of Records and Information in Legal Proceedings—20 CFR 403.100-403.155—0960-0619. Regulations at 20 CFR 403.100-403.155 of the Code of Federal Regulations establish SSA's policies and procedures for an individual; organization; or government entity to request official agency information, records, or testimony of an agency employee in a legal proceeding when the agency is not a party. The request, which respondents submit in writing to SSA, must: (1) Fully set out the nature and relevance of the sought testimony; (2) explain why the information is not available by other means; (3) explain why it is in SSA's interest to provide the testimony; and (4) provide the date, time, and place for the testimony. Respondents are individuals or entities who request testimony from SSA employees in connection with a legal proceeding.

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)
20 CFR 403.100-403.155	100	1	60	100

9. Function Report Adult-Third Party—20 CFR 404.1512 & 416.912—0960-0635. Individuals receiving or applying for Social Security Disability Insurance (SSDI) or 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	709,700	1	61	721,528

10. Request for Deceased Individual's Social Security Record—20 CFR 402.130—0960-0665. When a member of the public requests an individual's Social Security record, SSA needs the name and address of the requestor as well as a description of the requested record to process the request. SSA uses the information the respondent provides on Form SSA-711, or via an internet request through SSA's electronic Freedom of Information Act (eFOIA) website, to (1) verify the wage earner is deceased and (2) access the correct Social Security record. Respondents are members of the public requesting deceased individuals' Social Security records.

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)
Internet Request through eFOIA	49,800	1	7	5,810
SSA-711 (paper)	200	1	7	23
Total	50,000			5,833

11. Certification of Prisoner Identity Information—20 CFR 422.107—0960-0688. Inmates of Federal, State, or local prisons may need a Social Security card as verification of their Social Security number for school or work programs, or as proof of employment eligibility upon release from incarceration. Before SSA can issue a replacement Social Security card, applicants must show SSA proof of their identity. People who are in prison for an extended period typically do not have current identity documents. Therefore, under formal written agreement with the correctional institution, SSA allows prison officials to verify the identity of certain incarcerated U.S. citizens who need replacement Social Security cards. Information prison officials provide comes from the official prison files, sent on correctional facility letterhead. SSA uses this information to establish the applicant's identity in the replacement Social Security card process. The respondents are prison officials who certify the identity of prisoners applying for replacement Social Security cards.

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

Modality of completion	Number of responses	Frequency of response	Number of responses	Average burden per response (minutes)	Estimated total annual burden (hours)
Verification of Prisoner Identity Statements	1,000	200	200,000	3	10,000

12. Request to Pay Civil Monetary by Installment Agreement—20 CFR 498—0960-0776. When SSA imposes a civil monetary penalty (CMP) on individuals for various fraudulent conduct related to SSA-administrated programs, those individuals may request to pay the CMP through benefit withholding, or an installment agreement. To negotiate a monthly payment amount, fair to both the individual and the agency, SSA needs financial information from the individual. SSA uses Form SSA-640, Financial Disclosure for CMP Debt, to obtain the information necessary to determine a monthly installment repayment rate for individuals owing a CMP. The respondents are recipients of Social Security benefits and non-entitled individuals who must repay a CMP to the agency and choose to do so using an installment plan.

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-640	10	1	120	20

13. Notification of a Social Security Number (SSN) To An Employer for Wage Reporting—20 CFR 422.103(a)—0960-0778. Individuals applying for employment must provide a Social Security Number, or indicate they have applied for one. However, when an individual applies for an initial SSN, there is a delay between the assignment of the number and the delivery of the SSN card. At an individual's request, SSA uses Form SSA-132 to send the individual's SSN to an employer. Mailing this information to the employer: (1) Ensures the employer has the correct SSN for the individual; (2) allows SSA to receive correct earnings information for wage reporting purposes; and (3) reduces the delay in the initial SSN assignment and delivery of the SSN information directly to the employer. It also enables SSA to verify the employer as a safeguard for the applicant's personally identifiable information. The majority of individuals who take advantage of this option are in the United States with exchange visitor and student visas; however, we allow any applicant for an SSN to use the SSA-132. The respondents are individuals applying for an initial SSN who ask SSA to mail confirmation of their application or the SSN to their employers.

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-132	326,000	1	2	10,867

14. Social Security Administration Health IT Partner Program Assessment—Participating Facilities and Available Content Form—20 CFR 404.1614 and 416.1014—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 (minutes)	Estimated total annual burden (hours)
SSA-680	30	1	5	150

Date: August 1, 2018.

Faye Lipsky,

Reports Clearance Director, Social Security Administration.