2011-33627. 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 (PRA) of 1995, effective October 1, 1995. This notice includes revisions and one extension 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, DCRDP, Attn: Reports Clearance Officer, 1333 Annex Building, 6401 Security Blvd., Baltimore, MD 21235, Fax: [phone], Email 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 March 5, 2012. Individuals can obtain copies of the collection instruments by calling the SSA Reports Clearance Officer at [phone] or by writing to the above email address.

1. Application for Parent's Insurance Benefits—20 CFR 404.370-404.374, 20 CFR 404.601-404.603—0960-0012. Section 202(h) of the Social Security Act establishes the conditions of eligibility a claimant must meet to receive monthly benefits as a parent of a deceased worker. SSA uses information from form SSA-7-F6 to determine whether the claimant meets the eligibility and application criteria. The respondents are applicants for, and recipients of, Social Security Old Age, Survivors, and Disability Insurance benefits.

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

Collection method	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
Modernized Claims System (MCS)	153	1	15	38
MCS/Signature Proxy	158	1	14	37
Paper SSA-7-F6	4	1	15	1
Total	315			76

2. Statement of Living Arrangements, In-Kind Support and Maintenance—20 CFR 416.1130-416.1148—0960-0174. A recipient's need is the basis for determining Supplemental Security Income (SSI) payment amounts. Need is measured, in part, by the amount of income an individual receives. Income includes in-kind support and maintenance in the form of food and shelter provided by other persons. SSA uses information from 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, or who complete an SSI eligibility redetermination.

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

Collection method	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

3. Application for Supplemental Security Income—20 CFR 416.305-416.335, Subpart C—0960-0444. SSA collects information on the SSA-8001-BK to determine an applicant's eligibility for SSI and the SSI payment amounts. SSA employees also collect this information during interviews with members of the public who wish to file for SSI. SSA uses the information for two purposes: (1) To formally deny SSI for non-medical reasons when information the applicant provides results in ineligibility; or (2) to establish a disability claim, but defer the complete development of non-medical issues until SSA approves the disability. The respondents are applicants for SSI.

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

Collection method	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
Modernized SSI Claims System (MSSICS)	1,006,400	1	15	251,600
MSSICS/Signature Proxy	326,400	1	14	76,160
Paper SSA-8001-BK	27,200	1	18	8,160
Total	1,360,000			335,920

4. Statement of Funds You Provided to Another and Statement of Funds You Received—20 CFR 416.1103(f)—0960-0481. SSA uses forms SSA-2854 and SSA-2855 to gather information to verify if a loan is bona fide for SSI recipients. The SSA-2854 asks the lender for details on the transaction, and form SSA-2855 asks the borrower the same basic questions independently. Agency personnel then compare the two statements, gather evidence if needed, and make a decision on the validity of the bona fide status of the loan.

For SSI purposes, we consider a loan bona fide if it meets these requirements:

• Must be between a borrower and lender with the understanding that the borrower has an obligation to repay the money;
• Must be in effect at the time the cash goes to the borrower, that is, the agreement cannot come after the cash is paid; and
• Must be enforceable under State law, often there are additional requirements from the State.

In addition to these elements: (1) There must be an understanding between borrower and lender that the borrower is obligated to repay the money; (2) the loan agreement must be in effect at the time the borrower receives the cash proceeds; and, (3) the transaction must be enforceable under State law. State requirements generally demand the presence of other conditions before the agreement is a bona fide loan.

SSA collects this information at the time of initial application for SSI or at any point when an individual alleges being party to an informal loan while receiving SSI. SSA collects information on the informal loan through both interviews and mailed forms. The agency's field personnel conduct the interviews and mail the form(s) for completion, as needed. The respondents are SSI recipients and applicants, and individuals who lend money to them.

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

Collection method	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-2854	20,000	1	10	3,333
SSA-2855	20,000	1	10	3,333
Total	40,000			6,666

5. Certification of Low Birth Weight for SSI Eligibility—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 State Disability Determination Services (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: Extension of an OMB-approved information collection.

Collection method	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-3380	24,000	1	15	6,000

II. SSA submitted the information collections below to OMB for clearance. Your comments regarding 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 February 2, 2012. Individuals can obtain copies of the OMB clearance packages by calling the SSA Reports Clearance Officer at [phone] or by writing to the above email address.

1. Incoming and Outgoing Intergovernmental Personnel Act Assignment Agreement—5 CFR 334—0960-NEW. The Intergovernmental Personnel Act (IPA) mobility program provides for the temporary assignment of civilian personnel between the Federal Government and state and local governments, colleges and universities, Indian tribal governments, federally funded research and development centers, and other eligible organizations. The Office of Personnel Management (OPM) created a generic form, the OF-69, for agencies to use as a template when collecting information for the IPA assignment. The OF-69 collects specific information about the agreement including the name, Social Security number, job title, salary, classification, and address of the employee enrolled in the program, as well as the type of assignment, reimbursement arrangement, and explanation of how the assignment will benefit both SSA and the non-federal organization involved in the exchange. OPM directs agencies to use their own forms for recording these agreements. Therefore, SSA modified the OF-69 to meet our needs, creating the SSA-187 for incoming employees and the SSA-188 for outgoing employees. Respondents are the individuals we describe above who participate in the IPA exchange with SSA.

Type of Request: Existing collection in use without an OMB number.

Respondent type	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
Non-Federal employee	10	1	30	5
Non-Federal employer signers	20	1	5	2
Total	30			7

2. Public Information Campaign—0960-0544. Periodically, SSA sends various public information materials, including public service announcements, news releases, and educational tapes, to public broadcasting systems so they can inform the public about various programs and activities SSA conducts. SSA frequently sends follow-up business reply cards for these public information materials to obtain suggestions for improving them. The respondents are broadcast television sources.

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

Collection method	Number of respondents	Frequency of response	Number of responses	Average burden per response (minutes)	Estimated total annual burden (hours)
Reply Cards	1,000	2	2,000	1	33

3. Credit Card Payment Form—0960-0648. SSA uses the SSA-1414 to process: (1) Credit card payments from former employees and vendors with outstanding debts to the agency; (2) advance payments for reimbursable agreements; and (3) credit card payments for all Freedom of Information Act (FOIA) requests requiring payment. The respondents are former employees and vendors who have outstanding debts to the agency, entities who have reimbursable agreements with SSA, and individuals who request information through FOIA.

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

Collection instrument	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-1414	6,000	1	2	200

4. Medical Source Statement of Ability To Do Work-Related Activities (Physical and Mental)—20 CFR 404.1512-404.1513, 404.912-404.913, 404.1517, 416.917-0960 0662. In some instances, when a claimant appeals a denied disability claim and the claimant's medical sources cannot or will not give the agency sufficient evidence to determine whether the claimant is disabled, SSA may ask the claimant to have a consultative examination at the agency's expense. The medical providers who perform these consultative examinations provide a statement on forms HA-1151 and HA-1152 about the claimant's disability and ability to perform work-related activities. SSA uses the information to assess the work-related physical and mental capabilities of claimants who appeal SSA's previous determination on their issue of disability. The respondents are medical sources who provide reports based either on existing medical evidence or on consultative examinations.

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

Collection method	Number of respondents	Frequency of response	Number of responses	Average burden per response (minutes)	Estimated total annual burden (hours)
HA-1151	5,000	24	120,000	15	30,000
HA-1152	5,000	24	120,000	15	30,000
Total	10,000		240,000		60,000

Dated: December 28, 2011.

Naomi Sipple,

Management Analyst, Office of Regulations and Reports Clearance, Social Security Administration.