2014-22809. Agency Information Collection Activities: Proposed 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 (PRA) of 1995, effective October 1, 1995. This notice includes 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].

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 November 24, 2014. Individuals can obtain copies of the collection instruments by writing to the above email address.

1. Letter to Employer Requesting Information About Wages Earned By Beneficiary—20 CFR 416.703, 404.801 & 404.820—0960-0034. Social Security disability recipients receive payments based on their inability to engage in substantial gainful activity (SGA) because of a physical or mental condition. If the recipients work, SSA must evaluate and determine if they continue to meet the disability requirements of the law. Therefore, we use Form SSA-L725 to request monthly earnings information from the recipient's employer. We then use the earnings data to determine whether the recipient is engaging in SGA, since work after a recipient becomes entitled to benefits can cause a cessation of disability. The respondents are businesses that employ Social Security 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)
SSA-L725	150,000	1	40	100,000

2. Letter to Employer Requesting Wage Information—0960-0138. SSA must establish and verify wage information for Supplemental Security Income (SSI) applicants and recipients when determining SSI eligibility and payment amounts. SSA uses Form SSA-L4201 to collect wage data from employers. SSA uses the information to determine eligibility and proper payment amounts for SSI applicants and recipients. The respondents are employers of SSI applicants 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)
SSA-L4201	133,000	1	30	66,500

3. Statement of Living Arrangements, In-Kind Support, and Maintenance—20 CFR 416.1130-416.1148—0960-0174. SSA determines SSI payment amounts based on applicants' and recipients' needs. We measure individuals' needs, in part, by the amount of income they receive, including in-kind support and maintenance in the form of food and shelter provided by other persons. SSA uses Form SSA-8006-F4 to determine if in-kind support and maintenance exists for SSI applicants and recipients. This information also assists SSA in determining the income value of in-kind support and maintenance SSI applicants and recipients receive. The respondents are individuals who apply for SSI payments, or who complete an SSI eligibility redetermination.

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-8006-F4	173,380	1	7	20,228

4. Claimant's Recent Medical Treatment—20 CFR 404.1512 and 416.912—0960-0292. When Disability Determinations Services (DDS) deny a claim at the reconsideration level, the claimant has a right to request a hearing before an administrative law judge (ALJ). For the hearing, SSA asks the claimant to complete and return the HA-4631 if the claimant's file does not reflect a current, complete medical history as the claimant proceeds through the appeals process. ALJs must obtain the information to update and complete the record and to verify the accuracy of the information. Through this process, ALJs can ascertain whether the claimant's situation changed. The ALJs and hearing office staff use the response to make arrangements for consultative examination(s) and the attendance of an expert witness(es), if appropriate. During the hearing, the ALJ offers any completed questionnaires as exhibits and may use them to (1) refresh the claimant's memory; and (2) shape their questions. The respondents are claimant's requesting hearings on entitlement to Old Age, Survivors, and Disability Insurance (OASDI) benefits or SSI payments.

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-4631	200,000	1	10	33,333

5. Supplemental Security Income (SSI) Claim Information Notice—20 CFR 416.210—0960-0324. Section 1611(e)(2) of the Social Security Act requires individuals to file for and obtain all payments (annuities, pensions, disability benefits, veteran's compensation, etc.) for which they are eligible before qualifying for SSI payments. Individuals do not qualify for SSI if they do not first apply for all other benefits. SSA uses the information on Form SSA-L8050-U3 to verify and establish a claimant or recipient's eligibility under the SSI program. Respondents are SSI applicants or recipients who may be eligible for other payments from public or private programs.

Type of Request: Revision 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)
SSA-L-8050-U3	17,044	1	10	2,841

6. You Can Make Your Payment by Credit Card—0960-0462. Using information from Form SSA-4588 and its electronic application, Form SSA-4589, SSA updates individuals' Social Security records to reflect payments made on their overpayments. In addition, SSA uses this information to process payments through the appropriate credit card company. SSA provides the SSA-4588 when we inform an individual that we detected an overpayment. Individuals may choose to make a one-time payment or recurring monthly payments by completing and submitting the SSA-4588. SSA uses the SSA-4589 electronic intranet application only when individuals choose to telephone the Program Service Centers to make a one-time payment in lieu of completing Form SSA-4588. An SSA debtor contact representative completes the SSA-4589 electronic intranet application. Respondents are OASDI beneficiaries and SSI recipients who have outstanding overpayments.

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-4588 paper form	13,200	1	10	2,200
SSA-4589 electronic intranet application	221,316	1	5	18,443
Totals	234,516			20,643

7. Application for Extra Help with Medicare Prescription Drug Plan Costs—20 CFR 418.3101—0960-0696. The Medicare Modernization Act of 2003 mandated the creation of the Medicare Part D prescription drug coverage program and the provision of subsidies for eligible Medicare beneficiaries. SSA uses Form SSA-1020 or the Internet i1020, the Application for Extra Help with Medicare Prescription Drug Plan Costs, to obtain income and resource information from Medicare beneficiaries and to make a subsidy decision. The respondents are Medicare beneficiaries applying for the Part D low-income subsidy.

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-1020 (paper application form)	617,070	1	30	308,535
i1020 (online application)	282,228	1	25	117,595
Field Office Interview	155,687	1	30	77,844
Totals	1,054,985			503,974

8. Certification of Low Birth Weight for SSI Eligibility of Funds You Provided to Another and Statement of Funds You Received—20 CFR 416.931, 416.926a(m), and 416.924—0960-0720. Hospitals and claimants use Form SSA-3380 to provide medical information to local field offices (FO) and DDSs on behalf of infants with low birth weight. FOs use the form as a protective filing statement and the medical information to make presumptive disability findings, which allow expedited payment to eligible claimants. DDSs use the medical information to determine disability and continuing disability. The respondents are hospitals and claimants who have information identifying low birth weight babies and their medical conditions.

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	28,125	1	15	7,031

Dated: September 22, 2014.

Faye Lipsky,

Reports Clearance Director, Social Security Administration.