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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 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 extensions and revisions of OMB-approved information collections, and an information 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, 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.


Office of Management and Budget, Attn: Desk Officer for SSA, Fax: 202-395-6974, E-mail address:


Social Security Administration, DCBFM, Attn: Reports Clearance Officer, 1333 Annex Building, 6401 Security Blvd., Baltimore, MD 21235, E-mail address:

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 November 22, 2011. Individuals can obtain copies of the collection instruments by calling the SSA Reports Clearance Officer at 410-965-8783 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 as to 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.Start Printed Page 59181

Respondent typeNumber of respondentsFrequency of responseAverage burden per response (minutes)Estimated total annual burden (hours)
Non-federal employee, SSA-187101305
Non-federal employer signers, both SSA-187 & SSA-18820152

2. Coverage of Employees of State and Local Governments—20 CFR 404, Subpart M—0960-0425. The Code of Federal Regulations at 20 CFR part 404, Subpart M, prescribes the rules for states submitting reports of deposits and recordkeeping to SSA. States (and interstate instrumentalities) are required to provide wage and deposit contribution information for pre-1987 periods. Not all the states have completely satisfied their pending wage report and contribution liability with SSA for pre-1987 tax years. These regulations are needed until all pending items with all states are closed out, and to provide for collection of this information in the future, if necessary. The respondents are state and local governments or interstate instrumentalities.

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

Regulation sectionNumber of respondentsFrequency of responseAverage burden per response (hours)Estimated total annual burden (hours)
404. 1204 (a) & (b)5210.526
404. 1216 (a) & (b)521152

3. Medical Report on Adult with Allegation of Human Immunodeficiency Virus Infection; Medical Report on Child with Allegation of Human Immunodeficiency Virus Infection—20 CFR 416.993-416.994—0960-0500. SSA or state agencies (Disability Determination Services) use Forms SSA-4814-F5 and SSA-4815-F6 to collect information necessary to determine if an individual with the human immunodeficiency virus infection, who is applying for Supplemental Security Income (SSI), meets the requirements for presumptive disability payments. The respondents are the medical sources of the applicants for SSI disability payments.

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

FormNumber of respondentsFrequency of responseResponse time (minutes)Estimated total annual burden (hours)

4. 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 the 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.

Number of Respondents: 1,000.

Frequency of Response: 2.

Average Burden per Response: 1 minute.

Estimated Total Annual Burden: 33 hours.

5. Redetermination of Eligibility for Help with Medicare Prescription Drug Plan Costs—0960-0723. As per the requirements of the Medicare Modernization Act of 2003 (Pub. L. 108-173), SSA conducts low-income subsidy eligibility redeterminations for Medicare beneficiaries who currently receive the Medicare Part D subsidy and who meet certain criteria. Respondents complete Form SSA-1026-REDE under the following circumstances: (1) When individuals became entitled to the Medicare Part D subsidy during the past 12 months; (2) if they were eligible for the Part D subsidy for more than 12 months; or (3) if they reported a change in income, resources, or household size. Part D beneficiaries complete the SSA-1026-SCE when they need to report a potentially subsidy-changing event, including the following: (1) Marriage, (2) spousal separation, (3) divorce, (4) annulment of a marriage, (5) spousal death, or (6) moving back in with one's spouse following a separation. The respondents are current recipients of the Medicare Part D low-income subsidy who will undergo an eligibility redetermination for one of the reasons mentioned above.

Type of Request: Extension of an OMB-approved information collection.Start Printed Page 59182

FormNumber of respondentsFrequency of responseAverage burden per response (minutes)Estimated total annual burden (hours)

II. SSA submitted the information collection below to OMB for clearance. Your comments regarding the information collection 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 October 24, 2011. Individuals can obtain copies of the OMB clearance package by calling the SSA Reports Clearance Officer at 410-965-8783 or by writing to the above e-mail address.

Statement of Claimant or Other Person—Medical Resident FICA Refund Claims—20 CFR 404.702 and 416.570—0960-0786. The Internal Revenue Service (IRS) is contacting medical residents (and their employers) who filed Federal Insurance Contributions Act (FICA) refund claims from 1993 through 2005. Those medical residents who claimed their residencies were actually training, not employment, should not have been subject to FICA tax. The IRS made a decision to honor these claims and issue a full refund of FICA tax, plus statutory interest, to those who wish to participate in the refund resolution. SSA will remove wages from the participating residents' earnings records for the period of the refund requests, which will cause the residents' recorded earnings to decrease. This not only affects earnings for future retirement benefits, but also could adversely affect those residents (or their beneficiaries) who are currently receiving Social Security benefits.

To ensure they understand the potential impact on their benefits, SSA will call those residents who will be adversely affected and explain the effect on their Social Security benefits if they accept the IRS FICA refund. If SSA cannot reach the resident by phone, we will send a contact letter and the SSA-795-OP2 to the resident to complete and return to SSA to document the decision. Once we have the information, we will forward the signed forms to the IRS for the residents who no longer want the FICA refund.

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

Number of Respondents: 496.

Frequency of Response: 1.

Average Burden per Response: 4 minutes.

Estimated Total Annual Burden: 33 hours.

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Dated: September 20, 2011.

Faye Lipsky,

Reports Clearance Officer, Center for Reports Clearance, Social Security Administration.

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[FR Doc. 2011-24437 Filed 9-22-11; 8:45 am]