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Agency Information Collection Activities: Proposed Request and Comment Request

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The Social Security Administration (SSA) publishes a list of information collection packages that will require clearance by the Office of Management and Budget (OMB) in compliance with Pub. L. 104-13, the Paperwork Reduction Act of 1995, effective October 1, 1995. The information collection packages that may be included in this notice are for new information collections, approval of existing Start Printed Page 17726information collections, revisions to OMB-approved information collections, and extensions (no change) 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 on ways to minimize burden on respondents, including the use of automated collection techniques or other forms of information technology. Written comments and recommendations regarding the information collection(s) should be submitted to the OMB Desk Officer and the SSA Reports Clearance Officer. The information can be mailed and/or faxed to the individuals at the addresses and fax numbers listed below:

(OMB) Office of Management and Budget, Attn: Desk Officer for SSA, New Executive Building, Room 10235, 725 17th St., NW., Washington, DC 20503, Fax: 202-395-6974.

(SSA) Social Security Administration, DCFAM, Attn: Reports Clearance Officer, 1338 Annex Building, 6401 Security Blvd., Baltimore, MD 21235, Fax: 410-965-6400.

I. The information collections listed below are pending at SSA and will be submitted to OMB within 60 days from the date of this notice. Therefore, your comments should be submitted to SSA within 60 days from the date of this publication. You can obtain copies of the collection instruments by calling the SSA Reports Clearance Officer at 410-965-0454 or by writing to the address listed above.

1. Request for Waiver of Overpayment Recovery or Change in Repayment Notice—20 CFR 404.502-404.515 and 20 CFR 416.550-416.570—0960-0037. Form SSA-632 collects information on the circumstances surrounding overpayment of Social Security Benefits to recipients. SSA uses the information to determine whether recovery of an overpayment amount can be waived or must be repaid and, if repaid, how recovery will be made. The respondents are recipients of Social Security, Medicare or Supplemental Security Income (SSI) overpayments.

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

Number of Respondents: 500,000.

Frequency of Response: 1.

Average Burden Per Response: 120 minutes.

Estimated Annual Burden: 1,000,000 hours.

2. Requests for Self-Employment Information, Employee Information, Employer Information—20 CFR, Subpart A, 422.120—0960-0508. SSA uses Forms SSA-L2765, SSA-L3365 and SSA-L4002 to request correct information when an employer, employee or self-employed person reports an individual's earnings without a Social Security Number (SSN) or with an incorrect name or SSN. The respondents are employers, employees or self-employed individuals who are requested to furnish additional identifying information.

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

Number of Respondents: 3,000,000.

Frequency of Response: 1.

Average Burden Per Response: 10 minutes.

Estimated Annual Burden: 500,000 hours.

3. Disability Hearing Officer's Decision—20 CFR 404.917 and 416.1417—0960-0441. The Social Security Act requires that SSA provide an evidentiary hearing at the reconsideration level of appeal for claimants who have received an initial or revised determination that a disability did not exist or has ceased. Based on the hearing, the disability hearing officer (DHO) completes form SSA-1207 and all applicable supplementary forms (which vary depending on the type of claim). The DHO uses the information in documenting and preparing the disability decision. The form will aid the DHO in addressing the crucial elements of the case in a sequential and logical fashion. The respondents are DHOs in the State Disability Determination Services (DDS).

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

Number of Respondents: 65,000.

Frequency of Response: 1.

Average Burden Per Response: 45 minutes.

Estimated Annual Burden: 48,750 hours.

4. Real Property Current Market Value Estimate—0960-0471. The form SSA-L2794 is used to obtain current market value estimates of real property owned by applicants for, or beneficiaries of, SSI payments (or a person whose resources are deemed to such an individual). The value of an individual's resources, including non-home real property, is one of the eligibility requirements for SSI recipients. The respondents are individuals with knowledge of local real property values.

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

Number of Respondents: 5,438.

Frequency of Response: 1.

Average Burden Per Response: 20 minutes.

Estimated Annual Burden: 1,813 hours.

5. 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. State Agency adjudicative teams use the information gathered by these forms in combination with other medical function evidence to form a complete picture of a child's ability to function. This information is used to help determine if a child is disabled, especially in cases in which disability cannot be found on medical grounds alone. The respondents are applicants for Title XVI childhood disability benefits and their caregivers.

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

Number of Respondents: 650,000

Frequency of Response: 1.

Average Burden Per Response: 20 minutes.

Estimated Annual Burden: 216,667 hours.

6. Function Report—Third Party—20 CFR 404.1512 and 416.912—0960-0635. The Social Security Act requires claimants to provide medical and other evidence to prove they are disabled. The Act also gives the Commissioner of Social Security the authority to make rules and regulations about the nature and extent of the evidence required to prove disability as well as the methods of obtaining this evidence. The information collected from form SSA-3380 is needed to determine disability under Title II (Old-Age, Survivors and Disability Insurance (OASDI) and/or Title XVI (SSI). The form records information about the disability applicant's illnesses, injuries, conditions, impairment-related limitations, and ability to function. The respondents are individuals who are familiar with the applicant's disability, impairment, limitations, and ability to function.

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

Number of Respondents: 1,500,000.

Frequency of Response: 1.

Average Burden Per Response: 30 minutes.

Estimated Annual Burden: 750,000 hours.

7. Application for Benefits Under the Italy-U.S. International Social Security Agreement—0960-0445—20 CFR 404.1925. The information collected on Form SSA-2528 is required by SSA in order to determine entitlement to benefits. The respondents are applicants for old-age, survivors or disability benefits, who reside in Italy.

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

Number of Respondents: 200.

Frequency of Response: 1.

Average Burden Per Response: 20 minutes.

Estimated Annual Burden: 67 hours.

II. The information collection listed below has been submitted to OMB for clearance. Your comments on the information collections would be most useful if received by OMB and SSA within 30 days from the date of this publication. You can obtain a copy of the OMB clearance package by calling the SSA Reports Clearance Officer at 410-965-0454, or by writing to the addresses listed above.

1. Youth Transition Process Demonstration Evaluation Data Collection—To further the President's New Freedom Initiative goal of increasing employment of individuals with disabilities, SSA plans to award seven cooperative agreements for the purpose of developing service delivery systems to assist youth with disabilities to successfully transition from school to work. SSA is funding two coordinated contracts to provide (1) technical assistance and (2) an evaluation. SSA will work with the Evaluation Contractor to use the results to conduct a net outcome evaluation to determine the long-term effectiveness of the interventions, impacts and benefits of the demonstration. Evaluation data will be used by the projects to improve the efficiency of the project's operations; use of staff; linkages between the project and the agencies through which comprehensive services are arranged; and specific aspects of service delivery to better meet the needs of the targeted population. This type of project is authorized by sections 1110 and 234 of the Social Security Act. The respondents will be youth with disabilities who have enrolled in the project.

Type of Request: New Collection.

Number of Respondents: 5,000.

Frequency of Response: 4.

Average Burden Per Response: 15 minutes.

Estimated Annual Burden: 5,000 hours.

2. Certification of Contents of Document(s) or Record(s)—20 CFR 404.715 ff.—0960-NEW. SSA must secure evidence necessary for individuals to establish rights to benefits. Some of the types of evidence needed are evidence of age, relationship, citizenship, marriage, death, and military service. Form SSA-704 allows SSA employees, state record custodians, and other custodians of evidentiary documents to record information from documents and records to establish these types of evidence. SSA employees use this form but it also is used by state record custodians and other custodians of evidentiary documents.

Type of Request: Existing form not previously cleared by OMB.

Number of Respondents: 4,200.

Average Burden Per Response: 10 minutes.

Estimated Annual Burden: 700.

3. Questionnaire for Children Claiming SSI Payments—0960-0499. The information collected on form SSA-3881 is used by SSA to evaluate disability in children who apply for SSI payments. The respondents are individuals who apply for SSI payments for a disabled child.

Number of Respondents: 253,000.

Frequency of Response: 1.

Average Burden Per Response: 30 minutes.

Estimated Annual Burden: 126,500 hours.

4. Certificate of Responsibility for Welfare and Care of Child Not in Applicant's Custody—20 CFR 404.330 and 404.339—0960-0019. SSA uses the information collected on form SSA-781 to decide if “in care” requirements are met by non-custodial parent(s), who is filing for benefits based on having a child in care. The respondents are non-custodial wage earners whose entitlement to benefits depends upon having an entitled child in care.

Number of Respondents: 14,000.

Frequency of Response: 1.

Average Burden Per Response: 10 minutes.

Estimated Annual Burden: 2,333 hours.

5. Social Security Benefits Applications—20 CFR Subpart D, 404.310-404.311 and 20 CFR Subpart F, 404.601-401.603—0960-0618. One of the requirements for obtaining Social Security benefits is the filing of an application so that a determination may be made on the applicant's eligibility for monthly benefits. In addition to the traditional paper application, SSA has developed various options for the public to add convenience and operational efficiency to the application process. The total estimated number of respondents to all application collections formats is 3,843,369 with a cumulative total of 995,457 burden hours. The respondents are applicants for retirement insurance benefits (RIB), disability insurance benefits (DIB), and/or spouses' benefits.

Please note that burden hours for applications taken through the Modernized Claims System (MCS) are accounted for in the hardcopy collection formats. MCS is an electronic collection method that mirrors the hardcopy application formats. Guided by the MCS collection screens, an SSA representative interviews the applicant and inputs the information directly into SSA's application database. MCS offers the representative prompts based on the type of application being filed and the circumstances of the applicant. These prompts facilitate a more complete initial application, saving both the agency and applicant time. MCS also propagates identity and similar information within the application, which saves additional time.

Type of Request: Revision of an OMB-approved information collection (ISBA collection only).

Internet Social Security Benefits Application (ISBA)

ISBA, which is available through SSA's Internet site, is one method that an individual can choose to file an application for benefits. Individuals can use ISBA to apply for RIB, DIB and spouse's insurance benefits based on age. SSA gathers only information relevant to the individual applicant's circumstances and will use the information collected by ISBA to entitle individuals to RIB, DIB, and/or spouses' benefits. The respondents are applicants for RIB, DIB, and/or spouses benefits.

Number of Respondents: 169,000.

Frequency of Response: 1.

Average Burden Per Response: 21.4 minutes.

Estimated Annual Burden: 60,277 hours.

Paper Application Forms

Application for Retirement Insurance Benefits (SSA-1)

The SSA-1 is used by SSA to determine an individual's entitlement to retirement insurance benefits. In order to receive Social Security retirement insurance benefits, an individual must file an application with SSA. The SSA-1 is one application that the Commissioner of Social Security prescribes to meet this requirement. The information that SSA collects will be used to determine entitlement to retirement benefits. The respondents are individuals who choose to apply for Social Security retirement insurance.

Number of Respondents: 1,460,692.

Frequency of Response: 1.

Average Burden Per Response: 10.5 minutes.

Estimated Annual Burden: 255,621 hours.

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Application for Wife's or Husband's Insurance Benefits (SSA-2)

SSA uses the information collected on Form SSA-2 to determine if an applicant (including a divorced applicant) can be entitled to benefits as the spouse of the worker and the amount of the spouse's benefits. The respondents are applicants for wife's or husband's benefits, including those who are divorced.

Number of Respondents: 700,000.

Frequency of Response: 1.

Average Burden Per Response: 15 minutes.

Estimated Annual Burden: 175,000 hours.

Application for Disability Insurance Benefits (SSA-16)

Form SSA-16-F6 obtains the information necessary to determine whether the provisions of the Act have been satisfied with respect to an applicant for disability benefits, and detects whether the applicant has dependents who would qualify for benefits on his or her earnings record. The information collected on form SSA-16 helps to determine eligibility for Social Security disability benefits. The respondents are applicants for Social Security disability benefits.

Number of Respondents: 1,513,677.

Frequency of Response: 1.

Average Burden Per Response: 20 minutes.

Estimated Annual Burden: 504,559 hours.

6. Application Statement for Child's Insurance Benefits—20 CFR 404.350-404.368, 404.603, and 416.350—0960-0010. Title II of the Social Security Act provides for payment of monthly benefits to the children of an insured retired, disabled, or deceased worker, if certain conditions are met. The form SSA-4-BK is used by SSA to collect information needed to determine whether the child or children are entitled to benefits. The respondents are children of the worker or individuals who complete this form on their behalf.

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

Life claimsDeath claims
Number of Respondents925,000815,000
Frequency of Response11
Average Burden Per Response10.5 minutes5.5 minutes
Estimated Annual Burden161,875 hours74,708 hours

7. Modified Benefit Formula Questionnaire-Foreign Pension—0960-0561. The information collected on form SSA-308 is used by SSA to determine exactly how much (if any) of the foreign pension may be used to reduce the amount of the Social Security retirement or disability benefit under the modified benefit formula. The respondents are applicants for Social Security retirement/disability benefits.

Type of Request: Extension of OMB approved Information collection.

Number of Responses: 50,000.

Frequency of Response: 1.

Average Burden Per Response: 10 minutes.

Estimated Annual Burden: 8,333 hours.

8. Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits—20 CFR 404.2015 and 416.615—0960-0024. SSA uses the information collected on form SSA-787 to determine an individual's capability, or lack thereof, to handle his or her own benefits. This information also provides SSA with a means of selecting a representative payee, if this proves necessary. The respondents are beneficiaries' physicians.

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

Please Note:

The Federal Register notice published on February 4, 2004 at 69 FR 5380, cited the “type of request” as an “Extension of an OMB-approved information collection.” Since that time, SSA decided to revise the form to make minor changes, so we are submitting this information collection as a revision.

Number of Respondents: 120,000.

Frequency of Response: 1.

Average Burden Per Response: 10 minutes.

Estimated Annual Burden: 20,000 hours.

9. Physical Residual Functional Capacity Assessment and Mental Residual Functional Capacity Assessment—20 CFR 404.1545 and 416.945—0960-0431. The information collected by form SSA-4734 is used in the adjudication of disability claims involving physical and/or mental impairments. The form provides the State DDS with a standardized data collection format to evaluate impairment(s) and to present findings in a clear, concise, and consistent manner. The respondents are State DDSs administering Title II and Title XVI disability programs.

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

Please Note:

The Federal Register notice published on February 4, 2004 at 69 FR 5380, cited the “type of request” as an “Extension of an OMB-approved information collection.” Since that time, SSA decided to revise the form so we are submitting this information collection as a revision.

SSA-4734-BKSSA-4734-SUP
Number of Respondents1,625,095796,770.
Frequency of Response11.
Average Burden Per Response20 minutes20 minutes.
Estimated Annual Burden541,698 hours265,590 hours.

Total Estimated Annual Burden: 807,288 hours.

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Dated: March 30, 2004.

Elizabeth A. Davidson,

Reports Clearance Officer, Social Security Administration.

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[FR Doc. 04-7535 Filed 4-2-04; 8:45 am]

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