2021-18988. 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 an extension 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

Comments: https://www.reginfo.gov/​public/​do/​PRAMain. Submit your comments online referencing Docket ID Number [SSA-2021-0034].

(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 https://www.reginfo.gov/​public/​do/​PRAMain,, referencing Docket ID Number [SSA-2021-0034].

I. The information collection below is pending at SSA. SSA will submit it 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 November 1, 2021. Individuals can obtain copies of the collection instrument by writing to the above email address.

Registration for Appointed Representative Services and Direct Payment—0960-0732. SSA uses Form SSA-1699 to register appointed representatives of claimants before SSA who:

• Want to register for direct payment of fees;
• Registered for direct payment of fees prior to 10/31/09, but need to update their information;
• Registered as appointed representatives on or after 10/31/09, but need to update their information; or
• Received a notice from SSA instructing them to complete this form.

By registering these individuals, SSA: (1) Authenticates and authorizes them to do business with us; (2) allows them to access our records for the claimants they represent; (3) facilitates direct payment of authorized fees to appointed representatives; and, (4) collects the information we need to meet Internal Revenue Service (IRS) requirements to issue specific IRS forms if we pay an appointed representative in excess of a specific amount ($600). The respondents are appointed representatives who want to use Form SSA-1699 for any of the purposes cited in this Notice.

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)	Average theoretical hourly cost amount (dollars) *	Total annual opportunity cost (dollars) **
SSA-1699	10,382	1	20	3,461	* $71.59	** $247,773
* We based this figure on average Lawyers hourly wages, as reported by Bureau of Labor Statistics data (www.bls.gov/​oes/​current/​oes231011.htm).
** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.

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 October 4, 2021. Individuals can obtain copies of these OMB clearance packages by writing to [e-mail].

1. Request for Withdrawal of Application—20 CFR 404.640—0960-0015. Form SSA-521, Request for Withdrawal of Application, allows claimants to specify which application they want to withdraw and the reason for the withdrawal. Form SSA-521 is our preferred instrument for 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 Form 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)	Average theoretical hourly cost amount (dollars) *	Total annual opportunity cost (dollars) **
Respondents applying for or receiving Retirement, Survivors, or Health Insurance benefits	60,753	1	5	5,063	* $10.95	** $55,440
Respondents applying for or receiving Disability benefits	14,374	1	5	1,198	* 10.95	** 13,118
Totals	75,127			6,261		** 68,558
* We based this figure on the average DI payments based on SSA's current FY 2021 data (https://www.ssa.gov/​legislation/​2021FactSheet.pdf).
** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.

2. 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, Statement of Employer, 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)	Average theoretical hourly cost amount (dollars) *	Total annual opportunity cost (dollars) **
SSA-7011-F4	500	1	30	250	* $27.07	** $6,768
* We based this figure on average U.S. worker's hourly wages, as reported by Bureau of Labor Statistics data (https://www.bls.gov/​oes/​current/​oes_​nat.htm#00-0000).
** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.

3. Request for Workers' Compensation/Public Disability Benefit Information—20 CFR 404.408(e)—0960-0098. Individuals who received both Social Security disability payments and Worker's Compensation/Public Disability Benefits (WC/PDB) must notify SSA about their WC/PDB, so that the agency can reduce the claimants' Social Security disability payments accordingly. Recipients may submit evidence of their WC/PDB, such as a copy of their award notice or benefit check, or have their WC/PDB provider complete Form SSA-1709 to document their WC/PDB to SSA. The respondents are Federal, State, and local agencies, insurance carriers, and public or private self-insured companies administering WC/PDB benefits to disability recipients.

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)	Average theoretical hourly cost amount (dollars) *	Total annual opportunity cost (dollars) **
SSA-1709	120,000	1	15	30,000	* $26.65	** $799,500
* We based this figure by averaging both the average Federal, State, and Local Government hourly wages (https://www.bls.gov/​oes/​current/​naics3_​999000.htm), and the average Insurance Claims and Policy Processing Clerks hourly wages, as reported by Bureau of Labor Statistics data (https://www.bls.gov/​oes/​current/​oes439041.htm).
** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.

4. A Statement of Care and Responsibility for Beneficiary—20 CFR 404.2020, 404.2025, 408.620, 408.625, 416.620, and 416.625—0960-0109. SSA uses the information from Form SSA-788, Statement of Care and Responsibility for Beneficiary, to verify payee applicants' statements of concern, and to identify other potential payees. SSA is concerned with selecting the most qualified representative payee who will use Social Security benefits in the beneficiary's best interest. SSA considers factors such as the payee applicant's capacity to perform payee duties; awareness of the beneficiary's situation and needs; demonstration of past, and current concern for the beneficiary's well-being. If the payee applicant does not have custody of the beneficiary, SSA obtains information from the custodian for evaluation against information the applicant provides. Respondents are individuals who have custody of the beneficiary in cases where someone else has filed to be the beneficiary's representative payee.

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)	Average theoretical hourly cost amount (dollars) *	Total annual opportunity cost (dollars) **
SSA-788	134,000	1	10	22,333	* $27.07	** $604,554
* We based this figure on average U.S. citizen's hourly salary, as reported by Bureau of Labor Statistics data (https://www.bls.gov/​oes/​current/​oes_​nat.htm#00-00000).
** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.

5. Third Party Liability Information Statement—42 CFR 433.136-433.139—0960-0323. To reduce Medicaid costs, Medicaid state agencies identify third party insurers liable for medical care or services for Medicaid beneficiaries. Regulations at 42 CFR 433.136-433.139 require Medicaid state agencies to obtain this information on Medicaid applications and redeterminations as a condition of Medicaid eligibility. States may enter into agreements with the Commissioner of Social Security to make Medicaid eligibility determinations for aged, blind, and disabled beneficiaries in those states. Applications for and redeterminations of Supplemental Security Income (SSI) eligibility in jurisdictions with such agreements are applications and redeterminations of Medicaid eligibility.

Under these agreements, SSA obtains third party liability information using Form SSA-8019-U2, Third Party Liability Information Statement, and provides that information to the Medicaid state agencies. The Medicaid state agencies use the information to bill third parties liable for medical care, support, or services for a beneficiary to guarantee that Medicaid remains the payer of last resort. The respondents are SSI claimants and recipients.

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)	Average theoretical hourly cost amount (dollars) *	Average wait time in field office or for teleservice centers (minutes) **	Total annual opportunity cost (dollars) ***
SSA-8019-U2 (Paper)	200	1	6	20	* $19.01		*** $380
SSI Claims System (Intranet)	35,257	1	6	3,526	* 19.01	** 21	*** 301,613
Totals	35,457			3,546			*** 301,993
* We based this figure on averaging both the average DI payments based on SSA's current FY 2021 data (https://www.ssa.gov/​legislation/​2021FactSheet.pdf), and the average U.S. worker's hourly wages, as reported by Bureau of Labor Statistics data (https://www.bls.gov/​oes/​current/​oes_​nat.htm).
** We based this figure on averaging both the average FY 2021 wait times for field offices and teleservice centers, based on SSA's current management information data.
*** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.

6. Certificate of Election for Reduced Spouse's Benefits—20 CFR 404.421—0960-0398. SSA cannot pay reduced Social Security benefits to an already entitled spouse unless the spouse elects to receive reduced benefits and is (1) at least age 62, but under full retirement age; and (2) no longer caring for a child. In this situation, spouses who decide to elect reduced benefits must file Form SSA-25, Certificate of Election for Reduced Spouse's Benefits. SSA uses the information to pay qualified spouses who elect to receive reduced benefits. Respondents are entitled spouses seeking reduced Social Security 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)	Average theoretical hourly cost amount (dollars) *	Total annual opportunity cost (dollars) **
SSA-25	30,000	1	13	6,500	* $27.07	** $175,955
* We based this figure on average U.S. citizen's hourly salary, as reported by Bureau of Labor Statistics data (https://www.bls.gov/​oes/​current/​oes_​nat.htm#00-00000)
** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.

7. Coverage of Employees of State and Local Governments—20 CFR part 404, subpart M—0960-0425. The regulations at 20 CFR part 404, subpart M prescribe the rules for States to submit reports of deposits and recordkeeping to SSA. SSA requires States (and interstate instrumentalities) to provide wage and deposit contribution information for pre-1987 tax years. Since not all States have completely satisfied their pending wage report and contribution liability with SSA for pre-1987 tax years, SSA needs these regulations until we collect all pending items with the States, and to allow for collection of this information in the future, if necessary. The respondents are State and local governments or interstate instrumentalities.

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

Regulation section	Number of respondents	Frequency of response	Average burden per response (minutes)	Total annual burden (hours)	Average theoretical hourly cost amount (dollars) *	Total annual opportunity cost (dollars) **
404. 1204 (a) & (b)	52	1	30	26	* $28.74	** $747
404.1215	52	1	60	52	* 28.74	** 1,494
404. 1216 (a) & (b)	52	1	60	52	* 28.74	** 1,494
Totals	156			130		** 3,735
* We based this figure on an average of both the State Government hourly wages (https://www.bls.gov/​oes/​current/​naics4_​999200.htm), and the average Local Government hourly wages, as reported by Bureau of Labor Statistics data (https://www.bls.gov/​oes/​current/​naics4_​999300.htm).
** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.

8. Permanent Residence in the United States Under Color of Law (PRUCOL)—20 CFR 416.1615 and 416.1618—0960-0451. Under 20 CFR 416.1415 and 416.1618, 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) using the DHS Systemic Alien Verification for Entitlements (SAVE) program. SSA determines if the individual qualifies for PRUCOL status based on the SAVE program 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 responses	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)	Average theoretical hourly cost amount (dollars) *	Total annual opportunity cost (dollars) **
Personal Interview	1,049	1	5	87	* $27.07	** $2,355
* We based this figure on average U.S. worker's hourly wages, as reported by Bureau of Labor Statistics data (https://www.bls.gov/​oes/​current/​oes_​nat.htm#00-0000).
** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.

9. Request for Deceased Individual's Social Security Record—20 CFR 402.130—0960-0665. The Freedom of Information Act (FOIA), at 5 U.S.C. 552(a)(3) of the U.S. Code, provides instructions for members of the public to request records from Federal Agencies. When a member of the public requests an individual's Social Security record under FOIA, 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, Request for Deceased Individual's Social Security Record, 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)	Average theoretical hourly cost amount (dollars) *	Average wait time in field office or for teleservice centers (minutes) **	Total annual opportunity cost (dollars) ***
Internet Request through eFOIA	49,800	1	7	5,810	* $27.07		*** $157,277
SSA-711 (paper)	200	1	7	23	* 27.07	** 24	*** 2,788
Total	50,000			5,833			*** 160,065
* We based this figure on average U.S. worker's hourly wages, as reported by Bureau of Labor Statistics data (https://www.bls.gov/​oes/​current/​oes_​nat.htm#00-0000).
** We based this figure on the average FY 2021 wait times for field offices, based on SSA's current management information data.
** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.

10. Representative Payment—20 CFR 404.2011, 404.2025, 416.611, and 416.625—0960-0679. The regulations at 20 CFR 404.2011 and 416.611 allow SSA to make payments to recipients' representative payees if it may cause substantial harm for the beneficiaries to receive their payments directly. The regulations allow beneficiaries to dispute a finding that substantial harm exists by providing SSA with evidence to reevaluate the determination. In addition, sections 20 CFR 404.2025 and 416.625 describe the information representative payees must provide SSA about their continuing relationship and responsibility for the recipients, and explain how they use the recipients' payments to verify payee performance. The respondents are Title II and Title XVI recipients, and their representative payees.

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

Regulation section	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)	Average theoretical hourly cost amount (dollars) *	Total annual opportunity cost (dollars) **
404.2011(a)(1); 416.611(a)(1)	260	1	15	65	* $19.01	** $1,236
404.2025; 416.625	3,090	1	6	309	* 19.01	** 5,874
Totals	3,350			374		** 7,110
* We based this figure on averaging both the average DI payments based on SSA's current FY 2021 data (https://www.ssa.gov/​legislation/​2021FactSheet.pdf), and the average U.S. worker's hourly wages, as reported by Bureau of Labor Statistics data (https://www.bls.gov/​oes/​current/​oes_​nat.htm).
** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.

11. Function Report—Adult—20 CFR 404.1512 & 416.912—0960-0681. Individuals receiving or applying for Social Security disability insurance (SSDI) or SSI must provide medical evidence and other proof SSA requires to prove their disability. SSA staff, and, on SSA's behalf, State Disability Determination Services' (DDS) employees, collect the information via paper Form SSA-3373, or through an in-person or telephone interview for cases where we need information about a claimant's activities and abilities to evaluate the claimant's disability. We use the information to document how claimants' disabilities affect their ability to function, and to determine eligibility, or continued eligibility, for SSI and SSDI claims. The respondents are adult Title II and Title XVI claimants, or current recipients undergoing redeterminations of 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)	Average theoretical hourly cost amount (dollars) *	Average wait time in field office or for teleservice centers (minutes) **	Total annual opportunity cost (dollars) ***
SSA-3373	1,734,635	1	61	1,763,546	* $10.95	** 21	*** $25,958,815
* We based this figure on the average DI payments based on SSA's current FY 2021 data (https://www.ssa.gov/​legislation/​2021FactSheet.pdf).
** We based this figure on averaging both the average FY 2021 wait times for field offices and teleservice centers, based on SSA's current management information data.
*** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.

12. Request for Business Entity Taxpayer Information—0960-0731. SSA requires law firms or other business entities to complete Form SSA-1694, Request for Business Entity Taxpayer Information, if they wish to serve as appointed representatives and receive direct payment of fees from SSA. SSA uses the information to issue a Form 1099-MISC. SSA also uses the information to allow business entities to designate individuals to serve as entity administrators authorized to perform certain administrative duties on their behalf, such as providing bank account information, maintaining entity information, and updating individual affiliations. Respondents are law firms or other business entities with attorneys or other qualified individuals as partners or employees who represent claimants before SSA.

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)	Average theoretical hourly cost amount (dollars) *	Total annual opportunity cost (dollars) **
SSA-1694 (Paper)	366	1	20	122	* $61.03	** $7,446
BSO online submission	103	1	20	34	* 61.03	** 2,075
Totals	469			156		** 9,521
* We based this figure on the average legal occupation's hourly salary, as reported by Bureau of Labor Statistics data (https://www.bls.gov/​oes/​current/​oes_​nat.htm#00-00000).
** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.

13. Financial Disclosure for Civil Monetary Penalty (CMP) Debt—20 CFR 498—0960-0776. When SSA imposes a 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, 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)	Average theoretical hourly cost amount (dollars) *	Average wait time in field office (minutes) **	Total annual opportunity cost (dollars) ***
SSA-640	10	1	120	20	* $19.01	** 24	*** $456
* We based this figure on averaging both the average DI payments based on SSA's current FY 2021 data (https://www.ssa.gov/​legislation/​2021FactSheet.pdf), and the average U.S. worker's hourly wages, as reported by Bureau of Labor Statistics data (https://www.bls.gov/​oes/​current/​oes_​nat.htm).
** We based this figure on the average FY 2021 wait times for field offices, based on SSA's current management information data.
*** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.

Dated: August 30, 2021.

Naomi Sipple,

Reports Clearance Officer, Social Security Administration.