2010-4448. 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 (Pub. L. 104-13), the Paperwork Reduction Act of 1995, effective October 1, 1995. This notice includes revisions and extensions 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, e-mail, or fax your comments and recommendations on the information collection(s) to the OMB Desk Officer and SSA Reports Clearance Director to the following addresses or fax numbers.

(OMB), Office of Management and Budget, Attn: Desk Officer for SSA. Fax: [phone]. E-mail address: [e-mail].

(SSA), Social Security Administration, DCBFM, Attn: Director, Center for Reports Clearance, 1333 Annex Building, 6401 Security Blvd., Baltimore, MD 21235. Fax: [phone]. E-mail address: [e-mail].

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 May 3, 2010. Individuals can obtain copies of the collection instruments by calling the SSA Director for Reports Clearance at 410-965-0454 or by writing to the above e-mail address.

1. Application for Lump Sum Death Payment—20 CFR 404.390-404.392—0960-0013. SSA uses Form SSA-8-F4 to collect information needed to authorize payment of the lump sum death payment (LSDP) to a widow, widower, or children as defined in section 202(i) of the Social Security Act. Respondents complete the application for this one-time payment via paper form, telephone, or an in-person interview with SSA employees. Respondents are applicants for the LSDP.

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

Collection method	Number of respondents	Estimated completion time (minutes)	Burden hours
MCS	278,825	10	46,471
MCS/Signature Proxy	278,825	9	41,824
Paper	29,350	10	4,892
Totals:	587,000		93,187

2. Certificate of Responsibility for Welfare and Care of Child Not in Applicant's Custody—20 CFR 404.330, 404.339-341, and 404.348-404.349—0960-0019. SSA uses Form SSA-781 to determine if non-custodial parents who are filing for spouse's or mother's and father's benefits based on having a child in their care meet the in-care requirements. Respondents are applicants for spouse's and/or mother's and father's benefits.

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

Number of Respondents: 14,000.

Frequency of Response: 1.

Average Burden Per Response: 10 minutes.

Estimated Annual Burden: 2,333 hours.

3. Supplemental Statement Regarding Farming Activities of Person Living Outside the U.S.A.—0960-0103. SSA uses Form SSA-7163A to document beneficiary or claimant reports of working on a farm outside the United States (U.S.). Specifically, the information provided on this form helps us to determine if we should apply foreign work deductions to the recipient's benefits. We collect the information either annually or every other year, depending on the respondent's country of residence. Respondents are Social Security recipients engaged in farming activities outside the U.S.

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

Number of Respondents: 1,000.

Frequency of Response: 1.

Average Burden Per Response: 1 hour.

Estimated Annual Burden: 1,000 hours.

4. Disability Report—Appeal—20 CFR 404.1512, 416.912, 404.916(c), 416.1416(c), 405 Subpart C, 422.140—0960-0144. SSA requires disability claimants who are appealing an unfavorable disability determination to complete Form SSA-3441-BK. This form allows claimants to disclose any changes to their disability or resources that might influence SSA's unfavorable determination. SSA may use the information to: (1) Reconsider and review an initial disability determination; (2) review a continuing disability; and (3) evaluate a request for a hearing. This information assists the State Disability Determination Services and administrative law judges (ALJ) in: (1) Preparing for the appeals and hearings; and (2) issuing a determination or decision on an individual's entitlement (initial or continuing) to disability benefits. Respondents are individuals who appeal denial, reduction, or cessation of Social Security disability income and Supplemental Security Income (SSI) payments, or who are requesting a hearing before an ALJ.

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

Collection method	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated annual burden (hours)
SSA-3441 (Paper Form)	12,604	1	45	9,453
Electronic Disability Collect System (EDCS)	843,090	1	45	632,318
I3441 (Internet Form)	417,268	1	120	834,536
Totals	1,272,962			1,476,307

5. Request for Hearing by Administrative Law Judge—20 CFR 404.929, 404.933, 416.1429, 404.1433, 405.722, 418.1350—0960-0269. When SSA denies applicants' or beneficiaries' requests for new or continuing benefits, those applicants/beneficiaries are entitled to request a hearing to appeal the decision. SSA uses Form HA-501 to document such requests. Although SSA collects this information, the actual hearings take place before ALJs employed by the Department of Health and Human Services (HHS). The respondents are: (1) Applicants for or current recipients of various Social Security benefits who want to appeal SSA's denial of their requests for new or continued benefits; and (2) Medicare Part B recipients whom SSA has determined must pay the Medicare Part B Income-Related Monthly Adjustment Amount, both of whom wish to appeal this decision at a hearing before an HHS ALJ.

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

Number of Respondents: 669,469.

Frequency of Response: 1.

Average Burden per Response: 10 minutes.

Estimated Annual Burden: 111,578 hours.

6. Information about Joint Checking/Savings Accounts—20 CFR 416.120, 416.1208—0960-0461. SSA considers a person's resources when evaluating eligibility for SSI payments. Generally, we consider funds in checking and savings accounts to be resources owned by the individuals whose names appear on the account. Individuals applying for SSI, however, may rebut an assumption of ownership in a joint account if they submit certain evidence establishing the funds do not belong to them. SSA uses Form SSA-2574 to collect information from SSI applicants/recipients who object to the assumption they own all or part of the funds in a joint checking or savings account bearing their names. SSA collects information about the account from both the SSI applicant/recipient and other account holder(s). After receiving the completed form, SSA can determine if we should consider the account to be a resource for the SSI payments applicant/recipient. The respondents are applicants and recipients of SSI and individuals who list themselves as joint owners of financial accounts with SSI applicants/recipients.

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

Number of Respondents: 200,000.

Frequency of Response: 1.

Average Burden per Response: 7 minutes.

Estimated Annual Burden: 23,333 hours.

7. Request for Earnings and Benefit Estimate Statement—20 CFR 404.810—0960-0466. SSA uses the information collected by Form SSA-7004 to identify respondents' Social Security earnings records, extract posted earnings information, calculate potential benefit estimates, produce the resulting Social Security statements, and mail them to the requesters. The respondents are Social Security number holders requesting information about their Social Security earnings records and estimates of their potential benefits.

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

Modality	Number of respondents	Frequency of response	Average burden per response (minutes)	Total annual burden (hours)
Paper Version	127,000	1	5	10,583
Internet Version	426,000	1	5	35,500
Totals	553,000			46,083

8. Beneficiary Recontact Form—20 CFR 404.703, 404.705—0960-0502. SSA must ensure that recipients of disability payments continue to be eligible for their payments. Research has indicated benefit recipients may fail to report circumstances that affect their benefits. Two such cases are: (1) When parents receiving disability benefits for their child marry; and (2) the removal of an entitled child from parents' care. SSA uses Form SSA-1588-OCR-SM to ask mothers/fathers about their marital status and children in care to detect overpayments and avoid continuing payment to those are no longer entitled. Respondents are recipients of mother/father Social Security benefits.

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

Number of Respondents: 133,400.

Frequency of Response: 1.

Average Burden per Response: 5 minutes.

Estimated Annual Burden: 11,117 hours.

9. Complaint Form for Allegations of Discrimination in Programs or Activities Conducted by the Social Security Administration—0960-0585. SSA uses Form SSA-437 to investigate and formally resolve complaints of discrimination based on disability, race, color, national origin (including limited English proficiency), sex, sexual orientation, age, religion, or retaliation for having participated in a proceeding under this administrative complaint process in connection with an SSA program or activity. SSA also uses this form to review, investigate, and resolve complaints alleging discrimination based on status as a parent in education, training programs, or activities conducted by SSA. Individuals who believe SSA discriminated against them on any of the above bases may file a written complaint of discrimination. SSA uses the information to identify the complainant; identify the alleged discriminatory act; ascertain the date of such alleged act; obtain the identity of any individual(s) with information about the alleged discrimination; and ascertain other relevant information that would assist in the investigation and resolution of the complaint. Respondents are individuals who believe SSA or SSA employees, contractors, or agents in programs or activities conducted by SSA discriminated against them.

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

Number of Respondents: 140.

Frequency of Response: 1.

Average Burden per Response: 1 hour.

Estimated Annual Burden: 140 hours.

10. Social Security Benefits Application—20 CFR 404.310-404.311, 404.315-404.322, 404.330-404.333, 404.601-404.603, and 404.1501-404.1512—0960-0618. This collection comprises the various application modalities for retirement, survivors, and disability benefits. These modalities include paper forms (SSA Forms SSA-1, SSA-2, and SSA-16), Modernized Claims System (MCS) screens for in-person field office interview applications, and the Internet-based iClaim application. This information collection request (ICR) is for additions and revisions to the information collection.

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

Paper Forms/Accompanying MCS Screens Burden Information:

Collection method	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated annual burden (hours)
Form SSA-1
MCS	172,200	1	11	31,570
MCS/Signature Proxy	1,250,800	1	10	208,467
Paper	20,000	1	11	3,667
Medicare-only MCS	299,000	1	7	34,883
Medicare-only Paper	1,000	1	7	117
Totals	1,743,000			278,704
Form SSA-2
MCS	36,860	1	15	9,215
MCS/Signature Proxy	331,740	1	14	77,406
Paper	3,800	1	15	950
Totals	372,400			87,571
Form SSA-16
MCS	218,657	1	20	72,886
MCS/Signature Proxy	1,967,913	1	19	623,172
Paper	24,161	1	20	8,054
Totals	2,210,731			704,112
iClaim
iClaim 3rd Party	28,118	1	15	7,030
iClaim Applicant after 3rd Party Completion	28,118	1	5	2,343
First Party iClaim	541,851	1	15	135,463
Medicare-only iClaim	200,000	1	10	33,333
Totals	798,087			178,169

Aggregate Public Reporting Burden: 1,248,556 hours.

11. SSI Telephone Wage Reporting System (SSITWR)—20 CFR 416.701-0732—0960-0715. SSA requires SSI recipients to report changes that could affect their eligibility for and the amount of their SSI payments, such as changes in income, resources, and living arrangements. The SSITWR, formerly the Statement for SSI Monthly Wage Reporting (Telephone), enables SSI recipients to meet these requirements by providing them with a fully automated mechanism to report their monthly wages by telephone, instead of contacting their local field offices. The SSITWR allows callers to report their wages either by speaking their responses through voice recognition technology, or by keying in responses using the telephone key pad. To ensure the security of the information provided, SSITWR asks callers to provide information SSA can compare against its records for authentication purposes. Once the system authenticates the identity of the callers, the callers can speak or key in their wage data. The respondents are SSI recipients, deemors, and representative payees of recipients.

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

Collection method	Frequency of reporting	Number of respondents	Estimated completion time (minutes)	Burden (hours)
Training/Instruction	1	85,000	35	49,584
SSITWR	12	85,000	5	85,000
Total		*85,000		134,584
Note: * The same 85,000 respondents are completing both activities, so the actual total number of respondents is only 85,000.

12. Treating Physician Consultative Examination Interest Form—20 CFR 404.1519g—20 CFR 404.1519i—0960-0751. When an applicant for Social Security disability benefits has not consulted a physician for a specified period preceding the application, SSA will ask the applicant to complete a consultative examination (CE). If the applicant has a treating physician (TP), SSA sends a medical evidence of record request letter and Form SSA-84 to the applicant's TP; the TP completes the latter form and returns it to SSA to indicate interest in conducting the CE. If the TP does not return the form, SSA assumes the TP is not interested in performing the CE. Respondents are disability benefits applicants' treating physicians.

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

Number of Respondents: 168.

Frequency of Response: 1.

Average Burden Per Response: 5 minutes.

Estimated Annual Burden: 14 hours.

13. Claimant Travel Reimbursement Request—20 CFR 404.999a-20 CFR 404.99c—0960-0752. SSA sends Form SSA-104 to Social Security benefits recipients with a CE appointment notice. To receive reimbursement for their travel expenses to the CE, recipients must: (1) Submit an itemized list of expenditures for their round trip; and (2) complete, sign, and return the SSA-104 to SSA. SSA collects this information to determine the amount of reimbursement. Respondents are applicants for disability claims applying for reimbursement of travel expenses to a CE.

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

Number of Respondents: 11,092.

Frequency of Response: 1.

Average Burden Per Response: 10 minutes.

Estimated Annual Burden: 1,849 hours.

II. SSA has submitted the information collections listed below to OMB for clearance. Your comments on the information collections would be most useful if OMB and SSA receive them within 30 days from the date of this publication. To be sure we consider your comments, we must receive them no later than April 5, 2010. You can obtain a copy of the OMB clearance packages by calling the SSA Director for Reports Clearance at 410-965-0454 or by writing to the above e-mail address.

1. Farm Self-Employment Questionnaire—20 CFR 404.1082(c) & 404.1095—0960-0061. Section 211(a) of the Social Security Act requires the existence of a trade or business as a prerequisite for determining if an individual or partnership can claim net earnings from self-employment. During a personal interview, the requesting Social Security field office uses Form SSA-7165 to elicit the information necessary to establish the existence of an agricultural trade or business and subsequent covered earnings for Social Security entitlement purposes. The respondents are applicants for Social Security benefits whose entitlement depends on whether the worker has covered earnings from self-employment as a farmer.

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

Number of Respondents: 47,500.

Frequency of Response: 1.

Average Burden Per Response: 10 minutes.

Estimated Annual Burden: 7,917 hours.

2. Statement for Determining Continuing Eligibility Supplemental Security Income Payment—20 CFR 416.204—0960-0145. SSA uses the information from Form SSA-8202-BK to conduct low- and middle-error-profile (LEP-MEP) telephone or face-to-face redetermination (RZ) interviews with SSI recipients and representative payees. The information SSA collects during the interview is needed to determine whether SSI recipients have met and continue to meet all statutory and regulatory requirements for SSI eligibility and whether they have been, and are still receiving, the correct payment amount.

Note:

SSA published this information collection with the incorrect burden information on December 28, 2009 at 74 FR 68655. The correct information is below.

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

Form No.	Number of respondents	Frequency of response	Average burden per response (minutes)	Total annual burden (hours)
SSA-8202-BK	235,390	1	21	82,387
MSSICS	333,408	1	20	111,136
Totals	568,798			193,523

3. 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 uses Forms SSA-5062 and SSA-L5063 to obtain statements about food and/or shelter provided to SSI claimants or recipients. SSA uses this information to determine whether food and/or shelter are bona fide loans or if SSA should count them as income for SSI purposes. This determination can affect a claimant or recipient's eligibility for SSI and the amount of 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.

Number of Respondents: 131,080.

Frequency of Response: 1.

Average Burden Per Response: 10 minutes.

Estimated Annual Burden: 21,847 hours.

4. Request To Resolve Questionable Quarters of Coverage (QC); Request for QC History Based on Relationship—0960-0575. The Personal Responsibility and Work Opportunity Reconciliation Act states that aliens admitted for lawful residence who have worked and earned 40 qualifying QCs for Social Security purposes can generally receive State benefits. States complete Form SSA-512 to request clarification from SSA on questionable QC information. Specifically, States use this form to request QC information for an alien's spouse or child in cases where the alien does not sign a consent form giving permission to access his/her Social Security records. We can allocate QCs to a spouse and/or to a child under age 18, if needed, to obtain 40 qualifying QCs for the alien. The respondents are State agencies that require QC information to determine eligibility for benefits.

Note:

This is a correction notice. SSA published this information collection with the incorrect burden information on December 28, 2009 at 74 FR 68655. In addition, since we are revising the Privacy Act Statement, this is now a revision of an OMB-approved information collection.

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

Form No.	Number of respondents	Frequency of response	Average burden per response (minutes)	Total annual burden (hours)
SSA-512	25,000	1	2	833
SSA-513	25,000	1	2	833
Totals	50,000			1,666

5. Site Review Questionnaire for Volume and Fee-for-Service Payees and Beneficiary Interview Form—20 CFR 404.2035, 404.2065, 416.665, 416.701, and 416.708—0960-0633. SSA asks organizational representative payees to complete Form SSA-637, Site Review Questionnaire for Volume and Fee-for-Service Payees, to provide information on how they carry out their representative payee responsibilities, including how they manage beneficiary funds. SSA then obtains information from the beneficiaries these organizations represent via the SSA-639, Beneficiary Interview Form, to corroborate the payees' statements. Due to the sensitivity of the information, SSA employees always complete the forms based on the answers respondents give during the interview. The respondents are individuals, State and local governments, and non-profit and for-profit organizations that serve as representative payees and the beneficiaries they serve.

Note:

This is a correction notice. SSA published this information collection as an extension on December 08, 2009 at 74 FR 64801. Since we are revising the Privacy Act Statement, this is now a revision of an OMB-approved information collection.

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

Form No.	Number of respondents	Frequency of response	Average burden per response (minutes)	Total annual burden (hours)
SSA-637	2,001	1	120	4,002
SSA-639	9,341	1	10	1,557
Totals	11,342			5,559

6. Direct Deposit Sign-Up Form (Country)—31 CFR 210—0960-0686. SSA's International Direct Deposit Program allows beneficiaries living abroad to receive their payments via direct deposit to an account at a financial institution outside the United States. SSA uses Form SSA-1199 to obtain the direct deposit information for such foreign accounts. Routing account number information varies slightly for each foreign country, so we use a variation of the Treasury Department's Form SF-1199A for each country. The respondents are Social Security beneficiaries residing abroad who want SSA to deposit their benefits payments directly to a foreign financial institution.

Type of Request: Revision 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.

7. Certification of Prisoner Identity Information—20 CFR 422.107—0960-0688. This regulation stipulates that when a valid agreement is in place, prison officials may verify the identity of certain incarcerated U.S. citizens who need replacement Social Security cards. Information the prison officials provide will come from the official prison files, sent on prison 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 identities of prisoners applying for replacement Social Security cards.

Note:

This is a correction notice. SSA published this information collection as an extension on December 08, 2009 at 74 FR 64801. Since we are revising the Privacy Act Statement, this is now a revision of an OMB-approved information collection.

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

Number of Respondents: 1,000.

Frequency of Response: 200.

Average Burden per Response: 3 minutes.

Estimated Annual Burden: 10,000 hours.

8. Temporary Extension of Attorney Fee Payment System to Title XVI; 5-Year Demonstration Project Extending Fee Withholding and Payment Procedures to Eligible Non-Attorney Representatives; Definition of Past-Due Benefits; and Assessment for Fee Payment Services—20 CFR 404.1717, 404.1730(c)(1), 404.1730(c)(2)(i), 404.1730(c)(2)(ii), 416.1517, 416.1528(a), 416.1530(c)(1), 416.1530(c)(2)(i), 416.1530(c)(2)(i)—0960-0745. Section 302 of the Social Security Protection Act of 2004 (SSPA), Public Law 108-203, amended section 1631(d)(2) of the Social Security Act to temporarily extend the Title II attorney fee withholding and direct payment process to Title XVI. Section 303 of the SSPA directed SSA to develop and conduct a 5-year nationwide demonstration project to allow qualifying non-attorneys the option of fee withholding and direct payment of fees under both Titles II and XVI. SSA uses the information obtained through this demonstration project to administer fee withholding and direct payment to certain non-attorney representatives. Respondents are non-attorneys who are eligible to receive direct payment of fees for representing individuals before SSA.

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

Regulation section	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated annual burden (hours)
404.1730(c)(2)(i)	841	10/year	30	4,205
404.1730(c)(2)(ii)	600	1	3	30
416.1530(c)(2)(i)	561	10/year	30	2,805
416.1530(c)(2)(ii)	400	1	3	20
Totals	2,402			7,060

Dated: February 26, 2010.

Faye I. Lipsky,

Acting Reports Clearance Officer, Social Security Administration.