2010-11190. 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 and a collection in use without an OMB number.

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 July 12, 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. Request to Be Selected as a Payee—20 CFR 404.2010-404.2055, 416.601-416.665—0960-0014. An individual applying to be a representative payee for a Social Security or Supplemental Security Income (SSI) recipient completes Form SSA-11-BK. SSA obtains information from applicant payees regarding their relationship to the beneficiary, personal qualifications, concern for the beneficiary's well-being, and intended use of benefits if appointed as payee.

The respondents are individuals, private sector businesses and institutions, and state and local government institutions and agencies.

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)
Individuals/Households
Representative Payee System (RPS)	135,000	1	10.5	23,625
RPS/Signature Proxy	765,000	1	9.5	121,125
Paper Version	450,000	1	10.5	78,750
Totals	1,350,000			223,500
Private Sector
RPS	13,500	1	10.5	2,363
RPS/Signature Proxy	76,500	1	9.5	12,113
Paper Version	45,000	1	10.5	7,875
Totals	135,000			22,351
State/Local/Tribal Government
RPS	1,500	1	10.5	263
RPS/Signature Proxy	8,500	1	9.5	1,346
Paper Version	5,000	1	10.5	875
Totals	15,000			2,484
Grand Total:	1,500,000			248,335

2. Representative Payee Evaluation Report—20 CFR 404.2065 & 416.665—0960-0069. Sections 205(j) and 1631(a)(2) of the Social Security Act provide that SSA may appoint a representative payee to receive Title II benefits and/or Title XVI payments on behalf of individuals unable to manage those funds themselves. SSA requires the appointed representative payee to report once per year on how he or she used or conserved those funds. When a representative payee fails to adequately report to SSA, SSA conducts a face-to-face interview with the payee and completes Form SSA-624, Representative Payee Evaluation Report, to determine the continued suitability of the representative payee to serve as a payee. The respondents are individuals or organizations serving as representative payees for individuals receiving Title II benefits and/or Title XVI payments, and who fail to comply with SSA's statutory annual reporting requirement.

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

Number of Respondents: 266,000.

Frequency of Response: 1.

Average Burden per Response: 30 minutes.

Estimated Annual Burden: 133,000 hours.

3. Waiver of Your Right to Personal Appearance before an Administrative Law Judge—20 CFR 404.948(b)(l)(i) and 416.1448(b)(l)(i)—0960-0284. Applicants for Social Security benefits and SSI payments have the statutory right to appear in person (or through a representative) and present evidence about their claims at a hearing before an Administrative Law Judge (ALJ). If claimants wish to waive this right to appear before an ALJ, they must complete a written request. The applicants may use SSA Form HA-4608 for this purpose. The ALJ uses the information to document an individual's claim to show that an oral hearing is not preferred in the appellate process.

Respondents are claimants or their representatives for Title II benefits and/or Title XVI payments who request to waive their right to appear in person before an ALJ.

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

Number of Respondents: 12,000.

Frequency of Response: 1.

Average Burden per Response: 2 minutes.

Estimated Annual Burden: 400 hours.

4. Request for Change in Time/Place of Disability Hearing—20 CFR 404.914(c)(2) and 416.1414(c)(2)—0960-0348. At the request of the claimant or their representative, SSA schedules evidentiary hearings at the reconsideration level for claimants of Title II benefits and/or Title XVI payments when we deny their claims for disability. When claimants or their representatives find they are unable to attend the hearing, they complete Form SSA-769 to request a change in time or place of the hearing. SSA uses the information as a basis for granting or denying requests for changes and for rescheduling disability hearings. Respondents are claimants or their representative who wish to request a change in the time and/or place of their hearing.

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

Number of Respondents: 7,483.

Frequency of Response: 1.

Average Burden per Response: 8 minutes.

Estimated Annual Burden: 998 hours.

5. 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.

Number of Respondents: 1,000.

Frequency of Response: 1.

Average Burden per Response: 3 minutes.

Estimated Annual Burden: 50 hours.

6. Child Care Dropout Questionnaire—20 CFR 404.211(e)(4)—0960-0474. The Social Security Act and SSA's regulations permit the exclusion, from a disability computation period, of the years an individual was caring for his or her (or the spouse's) child under age 3 if he or she had no earnings in the benefit computation years. We call this the child-care dropout exclusion.

SSA uses the information from Form SSA-4162 to determine if an individual qualifies for this exclusion. Respondents are applicants for Title II disability benefits.

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

Number of Respondents: 2000.

Frequency of Response: 1.

Average Burden per Response: 5 minutes.

Estimated Annual Burden: 167 hours.

7. Requests for Self-Employment Information, Employee Information, Employer Information—20 CFR 422.120—0960-0508. SSA collects information on Forms SSA-L2765, SSA-L3365, and SSA-L4002 to credit the reported earnings to the proper earnings record. When SSA cannot identify Form W-2 wage data for an individual, we place the data in the earnings suspense file and send one of the forms cited above to the employee (and in certain instances to the employer) to obtain the correct name and Social Security number (SSN). If the respondent furnishes the name and SSN information that agrees with SSA's records, or provides information that resolves the discrepancy, SSA adds the reported earnings to the respondent's Social Security record. While SSA does not require respondents to provide the information to keep a benefit, if they do not furnish the missing or corrected information, we cannot credit the wages or self-employment income to the proper earnings record. The respondents are self-employed individuals and employees whose name and SSN information do not agree with SSA's records and their employers.

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-L2765	7,870	1	10	1,312
SSA-L3365	158,334	1	10	26,389
SSA-L4002	218,891	1	10	36,482
Totals	385,095			64,183

8. Appointment of Representative—20 CFR 404.1707, 404.1720, 404.1725, 410.684 and 416.1507—0960-0527. Persons claiming rights or benefits under the Social Security Act must notify SSA in writing when they appoint an individual to represent them in dealings with SSA. SSA uses the information collected on Form SSA-1696-U4 to verify the appointment of a representative. It also allows SSA to inform the representative of items that affect the recipient's claim, and allows the claimant to give permission to his or her appointed representative to designate a person to copy claims files. Respondents are applicant/recipients of Social Security benefits who notify SSA they have appointed a person to represent them in their dealings with SSA.

Number of Respondents: 551,520.

Frequency of Response: 1.

Average Burden per Response: 10 minutes.

Estimated Annual Burden: 91,920 hours.

9. 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. Forms SSA-3375-BK through SSA-3379-BK request information from the child's parent about the child's day-to-day functioning. The five different versions of the form contain questions about functioning appropriate to a particular age group; thus, respondents use only one version for each child.

The adjudicative team (disability examiners and medical/psychological consultants) of state Disability Determination Services (DDS) 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 child's ability to function and his or her impairment-related limitations. The adjudicative team uses the completed profile to determine whether the child's impairment(s) results in marked and severe functional limitations and whether the child is disabled. The respondents are parents and/or guardians of child applicants for SSI payments.

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

Number of Respondents: 500,000.

Frequency of Response: 1.

Average Burden per Response: 20 minutes.

Estimated Annual Burden: 166,667 hours.

10. Disability Report-Child—20 CFR 416.912—0960-0577— When claimants file a claim for childhood disability benefits under the SSI program, they must furnish medical and other evidence to prove they are disabled. Form SSA-3820 collects various types of information about a child's condition from treating sources and/or other medical sources of evidence. The DDS evaluators use the information to develop medical and school evidence and to assess the alleged disability. The information, together with medical evidence, forms the evidentiary basis upon which SSA makes its initial disability evaluation. The respondents are claimants seeking SSI childhood disability payments.

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-3820 (Paper Form)	500	1	60	500
Electronic Disability Collection System (EDCS)	422,000	1	34	239,133
i3820 (Internet)	93,293	1	120	186,586
Totals	515,793			426,219

11. eData Registration—20 CFR 401.45—0960-0757—The eData Services Web site allows various external organizations to submit files to a variety of SSA systems and in some cases receive return files. The users include state/local government agencies, other Federal agencies, and some private sector business entities. The SSA systems that process data transferred via eData include, but are not limited to, systems responsible for disability processing and benefit determination or termination. A sponsor within SSA who knows the requestor completes the registration form, SSA-118, and submits the information to SSA's User Interface Team (UIT). SSA uses the information on Form SSA-118 (Government-to-Government Services Online Web site Registration Form) to maintain the identity of the requestor within eData. Once this is completed, SSA provides the requestor with the new password and conducts a walkthrough of the eData Web site as necessary. The organization can also modify its online account (e.g., address change) by completing an online Form SSA-119 (Government-to-Government Service Online Web site Account Modification/Deletion Form).

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-118	925	1	15	231
SSA-119	2,500	1	15	625
Totals	3,425			856

12. Technical Updates to Applicability of the Supplemental Security Income (SSI) Reduced Benefit Rate for Individuals Residing in Medical Treatment Facilities—20 CFR 404.708(k)—0960-0758. Section 1611(e)(1)(A) of the Social Security Act states that no resident of a public institution is eligible for SSI benefits. However, Sections 1611(e)(1)(B) and (G) list certain exceptions to this provision that make it necessary for SSA to collect information about any SSI recipient who enters or leaves a medical treatment facility or other public or private institution. SSA's regulation, 20 CFR 404.708(k), establishes the reporting guidelines that implement this legislative requirement. SSA uses 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: Revision of an OMB-approved information collection. Number of Respondents: 34,200.

Frequency of Response: 1.

Average Burden per Response: 7 minutes.

Estimated Annual Burden: 3,990 hours.

13. Statement for Certificate of Election for Reduced Widower(er)'s and Surviving Divorced Spouse's Benefits—20 CFR 404.335—0960-0759. Section 202(q) of the Social Security Act provides for 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 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 collected on Form SSA-4111 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: Extension of an OMB-approved information collection.

Number of Respondents: 24,000.

Frequency of Response: 1.

Average Burden per Response: 15 minutes.

Estimated Annual Burden: 6,000 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 June 14, 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. 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 information from 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 Title II 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.

2. 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 DDS offices and ALJs 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 a denial, reduction, or cessation of Social Security disability income and 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

3. 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, 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 who must pay the Medicare Part B Income-Related Monthly Adjustment Amount and want to appeal SSA's decision at a hearing before an HHS ALJ.

Note:

This is a correction notice. SSA published this information collection as an extension on March 4, 2010 at 75 FR 9992. 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: 669,469.

Frequency of Response: 1.

Average Burden per Response: 10 minutes.

Estimated Annual Burden: 111,578 hours.

4. 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 this assumption of ownership in a joint account if they submit certain evidence that establishes the funds do not belong to them. SSA uses Form SSA-2574 to collect information from SSI applicants/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 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.

Number of Respondents: 200,000.

Frequency of Response: 1.

Average Burden per Response: 7 minutes.

Estimated Annual Burden: 23,333 hours.

5. SSI Monthly Wage Reporting (Telephone)—20 CFR 416.701-732—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 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 our 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.

Note:

This is a correction notice: SSA published the incorrect burden information for this collection at 75 FR 9992, on March 4, 2010. We are correcting this error here.

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	49,583
SSITWR	12	85,000	5	85,000
Total		* 85,000		134,583

Note:*

The same 85,000 respondents are completing both activities, so the actual total number of respondents is only 85,000.

6. Treating Physician Consultative Examination Interest Form—20 CFR 404.1519g-i—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 SSA-84 and returns it to SSA to indicate interest in conducting the CE. If the TP does not return the SSA-84, SSA assumes the TP is not interested in performing the CE. Respondents are disability benefit 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.

7. Claimant Travel Reimbursement Request—20 CFR 404.999a-d—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 trip; and (2) complete, sign, and return the SSA-104 to SSA. SSA collects this information to determine eligibility for and 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.

Dated: May 7, 2010.

Faye I. Lipsky,

Acting Center Director, Center for Reports Clearance, Social Security Administration.