2013-06350. 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 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, 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 Director, 107 Altmeyer 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 May 20, 2013. Individuals can obtain copies of the collection instruments by writing to the above email address.

1. Request for Earnings and Benefit Estimate Statement—20 CFR 404.810—0960-0466. Section 205(c)(2)(A) of the Social Security Act (Act) requires the Commissioner of SSA to establish and maintain records of wages paid to, and amounts of self-employment income derived by, each individual as well as the periods in which such wages were paid and such income derived. An individual may complete and mail Form SSA-7004 to SSA to obtain a Statement of Earnings or Quarters of Coverage. SSA uses the information Form SSA-7004 collects 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 of collection	Number of respondents	Frequency of response	Average burden per response (min)	Estimated total annual burden (hours)
SSA-7004 (paper)	17,219	1	5	1,435
SSA-7004 (Internet)	3,198,361	1	5	266,530
Totals	3,215,580			267,965

2. Agency/Employer Government Pension Offset Questionnaire—20 CFR 404.408(a)—0960-0470. When an individual is concurrently receiving Social Security spousal or surviving spousal benefits and a government pension, the individual may have the amount of Social Security benefits reduced by the government pension amount. This is the Government Pension Offset (GPO). SSA uses Form SSA-L4163 to collect accurate pension information from the Federal or State government agency paying the pension for purposes of applying the pension offset provision. The form is used only when (1) the claimant does not have the information; and (2) the pension-paying agency has not cooperated with the claimant. Respondents are State government agencies that have information SSA needs to determine if the GPO applies and the amount of offset.

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

Modality of collection	Number of respondents	Frequency of response	Average burden per response (min)	Estimated total annual burden (hours)
SSA-L4163	1,000	1	3	50

3. Employer Verification of Earnings After Death—20 CFR 404.821 and 404.822—0960-0472. When SSA records show a wage earner is deceased and we receive wage reports from an employer for the wage earner for a year subsequent to the year of death, SSA mails the employer Form SSA-L4112 (Employer Verification of Earnings After Death). SSA uses the information Form SSA-L4112 provides to verify wage information previously received from the employer is correct for the employee and the year in question. The respondents are employers who report wages for employees who have died.

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

Modality of collection	Number of respondents	Frequency of response	Average burden per response (min)	Estimated total annual burden (hours)
SSA-L4112	50,000	1	10	8,333

4. Function Report—Child: Birth to 1st Birthday (SSA-3375), Age 1 to 3rd Birthday (SSA-3376), Age 3 to 6th Birthday (SSA-3377), Age 6 to 12th Birthday, (SSA-3378), and Age 12 to 18th Birthday (SSA-3379)—20 CFR 416.912—0960-0542. SSA uses Forms SSA-3375-BK through SSA-3379-BK in the disability determination process to request information from a child's parent or guardian for children applying for Supplemental Security Income (SSI). The five different versions of the form contain questions about the child's day-to-day functioning appropriate to a particular age group; thus, respondents use only one version of the form for each child.

The adjudicative team (disability examiners and medical/psychological consultants) of State disability determination services offices collect the information on the appropriate version of this form (in conjunction with medical and other evidence) to form a complete picture of the children's ability to function and their impairment-related limitations. The adjudicative team uses the completed profile to determine whether each child's impairment(s) results in marked and severe functional limitations and whether each child is disabled. The respondents are parents and guardians of child applicants for SSI.

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

Modality of completion	Number of respondents	Frequency of response	Average burden per response (min)	Estimated total annual burden (hours)
Function Report—Child: (SSA-3375-BK through SSA-3379-BK)	660,000	1	20	220,000

5. 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 (min)	Estimated total annual burden (hours)
SSA-1699	52,800	1	20	17,600

6. Technical Updates to Applicability of the Supplemental Security Income (SSI) Reduced Benefit Rate for Individuals Residing in Medical Treatment Facilities—20 CFR 416.708(k)—0960-0758. Section 1611(e)(1)(A) of the Act states that residents of public institutions are ineligible for SSI. However, Sections 1611(e)(1)(B) and (G) list certain exceptions to this provision making it necessary for SSA to collect information from SSI recipients who enter or leave a medical treatment facility or other public or private institution. SSA's regulation 20 CFR 416.708(k) establishes the reporting guidelines that implement this legislative requirement. SSA collects the information to determine eligibility for SSI and the payment amount. The respondents are SSI recipients who enter or leave an institution.

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

Modality of completion	Number of respondents	Frequency of response	Average burden per response (min)	Estimated total annual burden (hours)
Technical Updates Statement	34,200	1	7	3,990

7. Statement for Certificate of Election for Reduced Widow(er)'s and Surviving Divorced Spouse's Benefits—20 CFR 404.335—0960-0759. Section 202(q) of the Act provides SSA the authority to reduce benefits under certain conditions when elected by a title II beneficiary. However, reduced benefits are not payable to an already entitled spouse (or divorced spouse) who:

• Is at least age 62 and under full retirement age in the month of the number holder's death; and
• Is receiving both reduced spouse's (or divorced spouse's) benefits and either retirement or disability benefits in the month before the month of the number holder's death.

To elect reduced widow(er) benefits, a recipient completes Form SSA-4111. SSA uses the information Form SSA-4111 collects to pay a qualified dually entitled widow(er) (or surviving divorced spouse) who elects to receive a reduced widow(er) benefit. The respondents are qualified dually entitled widow(er)s (or surviving divorced spouse) who elect to receive a reduced widow(er) benefit.

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

Modality of completion	Number of respondents	Frequency of response	Average burden per response (min)	Estimated total annual burden (hours)
SSA-4111	30,000	1	2	1,000

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 30 days from the date of this publication. To be sure we consider your comments, we must receive them no later than April 19, 2013. Individuals can obtain copies of the OMB clearance packages by writing to [e-mail].

1. Statement for Determining Continuing Eligibility, Supplemental Security Income Payment(s)—416.204—0960-0416. SSA conducts disability redeterminations to determine if SSI recipients (1) met and continue to meet all statutory and regulatory requirements for SSI eligibility and (2) are receiving the correct SSI payment amount. SSA makes these redeterminations through periodic use of Form SSA-8203-BK. SSA conducts this legally mandated information collection in field offices via personal contact (face-to-face or telephone interview) using the automated Modernized SSI Claim System (MSSICS). The respondents are SSI recipients or their representative payees.

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

Modality of collection	Number of respondents	Frequency of response	Average burden per response (min)	Estimated total annual burden (hours)
MSSICS	810,824	1	20	270,275
MSSICS/Signature Proxy	777,085	1	19	246,077
Paper	27,824	1	20	9,275
Totals	1,615,733			525,627

2. Application for Benefits Under the Italy-U.S. International Social Security Agreement—20 CFR 404.1925—0960-0445. As per the November 1, 1978 agreement between the United States and Italian Social Security agencies, residents of Italy filing an application for U.S. Social Security benefits directly with one of the Italian Social Security agencies must complete Form SSA-2528. SSA uses Form SSA-2528 to establish age, relationship, citizenship, marriage, death, military service, or to evaluate a family bible or other family record when determining eligibility for benefits. The Italian Social Security agencies assist applicants in completing Form SSA-2528 and then forward the application to SSA for processing. The respondents are individuals living in Italy who wish to file for U.S. 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 (min)	Estimated total annual burden (hours)
SSA-2528	300	1	20	100

3. 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. Generally, we consider funds in checking and savings accounts as resources owned by the individuals whose names appear on the account. However, individuals applying for SSI may rebut this assumption of ownership in a joint account by submitting certain evidence to establish the funds do not belong to them. SSA uses Form SSA-2574 to collect information from SSI applicants and recipients who object to the assumption that 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 the other account holder(s). After receiving the completed form, SSA determines if we should consider the account to be a resource for the SSI 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.

Modality of completion	Number of respondents	Frequency of response	Average burden per response (min)	Estimated total annual burden (hours)
SSA-2574 Paper Form	50,000	1	7	5,833
Modernized SSI Claims System	150,000	1	7	17,500
Totals	200,000			23,333

4. Real Property Current Market Value Estimate—0960-0471. SSA considers an individual's resources when evaluating eligibility for SSI payments. The value of an individual's resources, including non-home real property, is one of the eligibility requirements for SSI payments. SSA obtains current market value estimates of the claimant's real property through Form SSA-L2794. We allow respondents to use readily available records to complete the form, or we can accept their best estimates. We use this form as part of initial applications and in post-entitlement situations. The respondents are small business operators in real estate, State and local government employees tasked with assessing real property values, and other individuals knowledgeable about local real estate values.

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

Modality of completion	Number of respondents	Frequency of response	Average burden per response (min)	Estimated total annual burden (hours)
SSA-L2794	5,438	1	20	1,813

5. Certification of Contents of Document(s) or Record(s)—20 CFR 404.715—0960-0689. SSA established procedures for individuals to provide the evidence necessary to establish rights to Social Security benefits. Examples of such evidence categories include age, relationship, citizenship, marriage, death, and military service. Form SSA-704 allows SSA employees, State record custodians, and other custodians of evidentiary documents to certify and record information from original documents and records under their custodial ownership to establish these types of evidence. SSA uses Form SSA-704 in situations where individuals cannot produce the original evidentiary documentation required to establish benefits eligibility. The respondents are State record custodians and other custodians of evidentiary documents.

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

Modality of completion	Number of respondents	Frequency of response	Average burden per response (min)	Estimated total annual burden (hours)
SSA-704	4,800	1	10	800

6. Supplemental Security Income Wage Reporting (Telephone and Mobile)—20 CFR 416.701-732—0960-0715. SSA requires SSI recipients to report changes which could affect their eligibility for, and the amount of, their SSI payments, such as changes in income, resources, and living arrangements. SSA's SSI Telephone Wage Reporting (SSITWR) and SSI Mobile Wage Reporting (SSIMWR) enable SSI recipients to meet these requirements via an automated mechanism to report their monthly wages by telephone and mobile application, instead of contacting their local field offices. The SSITWR allows callers to report their wages by speaking their responses through voice recognition technology, or by keying in responses using a telephone key pad. The SSIMWR allows recipients to report their wages through the mobile wage reporting application on their smartphone. SSITWR and SSIMWR systems collect the same information and send it to SSA over secure channels. To ensure the security of the information provided, SSITWR and SSIMWR ask respondents to provide information SSA can compare against our records for authentication purposes. Once the system authenticates the identity of the respondents, they can report their wage data. The respondents are SSI recipients, deemors, or their representative payees.

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

Modality of completion	Number of respondents	Frequency of response	Average burden per response (min)	Estimated total annual burden (hours)
Training/Instruction*	85,000	1	35	49,583
SSITWR	80,000	12	5	80,000
SSIMWR	5,000	12	3	3,000
Total	85,000			132,583
*Note: The same 85,000 respondents are completing training and a modality of collection, therefore the actual total number of respondents is still 85,000.

7. Certificate of Incapacity—5 CFR 890.302(d)—0960-0739. Rules governing the Federal Employee Health Benefits (FEHB) plan require a physician to verify the disability of Federal employees' children ages 26 and over for such children to retain health benefits under their employed parents' plans. The physician must verify that the adult child's disability (1) Pre-dates the child's 26th birthday; (2) is very serious; and (3) will continue for at least one year. Physicians use Form SSA-604, the Certificate of Incapacity, to document this information. The respondents are physicians of SSA employees' children ages 26 or over who are seeking to retain health benefits under their parent's FEHB coverage.

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

Modality of completion	Number of respondents	Frequency of response	Average burden per response (min)	Estimated total annual burden (hours)
SSA-604	50	1	45	38

8. Centenarian Project Development Worksheets: Face-to-Face Interview and Telephone Interview—20 CFR 416.204(b) and 422.135—0960-0780. SSA conducts interviews with centenary title II beneficiaries and title XVI recipients age 100 and older to: (1) Assess if the beneficiaries are still living; (2) prevent fraud, through either identity misrepresentation or representative payee misuse of funds; and (3) evaluate the well-being of the beneficiaries. SSA field office personnel obtain the information through one-time interviews with the centenarians. If the centenarians have representatives or caregivers, SSA personnel invite them to the interviews. During the interview, SSA employees make overall observations of the centenarian and their representative payee (if applicable). The interviewer uses the appropriate Centenarian Development Worksheet as a guide for the interview, in addition to documenting findings during the interview. Non-completion of the Worksheets, or refusal of the interview, does not result in the suspension of the centenarian's payments. SSA conducts the interview either over the telephone or through a face-to-face discussion with the centenarian. This is a national project for our title II beneficiaries and title XVI recipients. Respondents are SSI recipients or Social Security beneficiaries 100 years old or older, their representative payees, or their caregivers.

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

Modality of completion	Number of respondents	Frequency of response	Average burden per response (min)	Estimated total annual burden (hours)
Centenarian Worksheets: Face-to-Face Interview; Telephone Interview	22,000	1	15	5,500

Dated: March 15, 2013.

Faye Lipsky,

Reports Clearance Director, Social Security Administration.