Skip to Content


Agency Information Collection Activities: Comment Request

Document Details

Information about this document as published in the Federal Register.

Document Statistics
Document page views are updated periodically throughout the day and are cumulative counts for this document including its time on Public Inspection. Counts are subject to sampling, reprocessing and revision (up or down) throughout the day.
Enhanced Content

Relevant information about this document from provides additional context. This information is not part of the official Federal Register document.

Published Document

This document has been published in the Federal Register. Use the PDF linked in the document sidebar for the official electronic format.

Start Preamble

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 (PRA), effective October 1, 1995. This notice includes revisions 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: 202-395-6974, Email address:

(SSA), Social Security Administration, OLCA, Attn: Reports Clearance Director, 3100 West High Rise, 6401 Security Blvd., Baltimore, MD 21235, Fax: 410-966-2830, Email address:

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 October 20, 2014. Individuals can obtain copies of the OMB clearance packages by writing to

1. Marital Relationship Questionnaire—20 CFR 416.1826—0960-0460. SSA uses Form SSA-4178, Marital Relationship Questionnaire, to determine if unrelated individuals of the opposite sex who live together are misrepresenting themselves as husband and wife. SSA needs this information to determine whether we are making correct payments to couples and individuals applying for or currently receiving Supplemental Security Income (SSI) payments. The respondents are applicants for and recipients of SSI payments.

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

Modality of completionNumber of respondentsFrequency of responseAverage burden per response (minutes)Total estimated annual burden (hours)

2. SSI Notice of Interim Assistance Reimbursement (IAR)—0960-0546. Section 1631(g) of the Social Security Act authorizes SSA to reimburse an IAR agency from an individual's retroactive SSI payment for assistance the IAR agency gave the individual for meeting basic needs while an SSI claim was pending or SSI payments were suspended or terminated. The State or local agency needs an IAR agreement with SSA to participate in the IAR program. The individual receiving the IAR payment signs an authorization form with an IAR agency to allow SSA to repay the IAR agency for funds paid in advance prior to SSA's determination on the individual's claim. The authorization represents the individual's intent to file for SSI, if they did not file an application prior to SSA receiving the authorization. Agencies who wish to enter into an IAR agreement with SSA need to meet the following requirements:

(a) Reporting Requirements—Each IAR agency agrees to:

(1) Notify SSA of receipt of an authorization for initial claims or cases they are appealing, and submit a copy of that authorization either through a manual or electronic process;

(2) inform SSA of the amount of reimbursement;

(3) submit a written request for dispute resolution on a determination;

(4) notify SSA of interim assistance paid (using the SSA-8125 or the SSA-L8125-F6);

(5) inform SSA of any deceased claimants who participate in the IAR program and;

(6) review and sign an agreement with SSA.

(b) Recordkeeping Requirements—The IAR agencies agree to retain all notices, agreement, authorizations, and accounting forms for the period defined in the IAR agreement for the purposes of SSA verifying transactions covered under the agreement.

(c) Third Party Disclosure Requirements: Each participating IAR agency agrees to send written notices from the IAR agency to the recipient Start Printed Page 56429regarding payment amounts and appeal rights.

(d) Periodic Review of Agency Accounting Process—The IAR agency makes the IAR accounting records of paid cases available for SSA review and verification. SSA conducts reviews either onsite or through the mail of the authorization forms, notices to the claimant and accounting forms. Upon completion of the review, SSA provides a written report of findings to the IAR agency director.

The respondents are State IAR officers.

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

Modality of completionNumber of respondents (States)Frequency of responseNumber of responsesAverage burden per response (minutes)Total estimated annual burden (hours)
Reporting Requirements
(a) State notification of receipt of authorization (Electronic Process)11Once per SSI Claimant97,33011,622
(b) State submission of copy of authorization (Manual Process)27Once per SSI Claimant68,40533,420
(c) State submission of amount of IA paid to recipients (using eIAR)38Once per SSI Claimant101,352813,514
(d) State request for determination—dispute resolution(1)As needed2301
(e) State computation of reimbursement due from SSA using paper Form SSA-L8125-F638Once per SSI Claimant1,52430762
(f) State notification to SSA of deceased claimant20As needed when SSI claimant dies while claim is pending401510
(g) State reviewing/signing of IAR Agreement38Once during life of the IAR agreement382 12456
Recordkeeping Requirements
(h) Maintenance of authorization forms38One form per SSI claimant3 165,73538,287
(i) Maintenance of accounting forms and notices38One set per SSI claimant101,35235,068
Third Party Disclosure Requirements
(j) Written notice from State to recipient regarding amount of payment38One per SSI claimant101,352711,824
Periodic Review of Agency Accounting Process
(k) Retrieve and consolidate authorization and accounting forms12One set of forms per SSI claimant for review by SSA once every 2 to 3 years12336
(l) Participate in periodic review12For review by SSA once every 2 to 3 years1216192
(m) Correct administrative and accounting discrepancies6To correct errors discovered by SSA in periodic review6424
Total Administrative Burden
1 Average of about 2 States per year.
2 Hours.
3 Includes both denied and approved SSI claims.

3. Medical Source Statement of Ability To Do Work Related Activities (Physical and Mental)—20 CFR 404.1512-404.1514, 404.912-404.914, 404.1517, 416.917, 404.1519-404.1520, 416.919-416.920, 404.946, 416.946, 404-1546—0960-0662. In some instances when a claimant appeals a denied disability claim, SSA may ask the claimant to have a consultative examination, at the agency's expense, if the claimant's medical sources cannot or will not give the agency sufficient evidence to determine whether the claimant is disabled. The medical providers who perform these consultative examinations provide a statement about the claimant's state of disability. Specifically, these medical source statements determine the work-related capabilities of these claimants. SSA collects the medical data on the HA-1151 and HA-1152 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.Start Printed Page 56430

Modality of completionNumber of respondentsFrequency of responseNumber of responsesAverage burden per responseTotal estimated annual burden (hours)

4. Electronic Records Express—20 CFR 404.1512 and 416.912—0960-0753. Electronic Records Express (ERE) is a Web-based SSA program that allows medical and educational providers to electronically submit disability claimant data to SSA. Both medical providers and other third parties with connections to disability applicants or recipients (e.g., teachers and school administrators for child disability applicants) use this system once they complete the registration process. SSA employees and State agency employees request the medical and educational records collected through the ERE Web site. The agency uses the information collected through ERE to make a determination on an Application for Benefits. We also use the ERE Web site to order and receive consultative examinations when we are unable to collect enough medical records to determine disability findings. The respondents are medical providers who evaluate or treat disability claimants or recipients, and other third parties with connections to disability applicants or recipients (ex: Teachers and school administrators for child disability applicants), who voluntarily choose to use ERE for submitting information.

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

Modality of completionNumber of respondentsFrequency of responseAverage burden per response (minutes)Total estimated annual burden (hours)

5. Application for Access to SSA Systems—20 CFR 401.45—0960-0791. SSA uses Form SSA-120, Application for Access to SSA Systems, to allow limited access to SSA's information resources for SSA employees and non-Federal employees (contractors). SSA requires supervisory approval, and local or component Security Officer review prior to granting this access. The respondents are SSA employees and non-Federal Employees (contractors) who require access to SSA systems to perform their jobs.

Note: Because SSA employees are Federal workers exempt from the requirements of the PRA, the burden below is only for SSA contractors.

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

Modality of completionNumber of respondentsFrequency of responseAverage burden per response (minutes)Total estimated annual burden (hours)
SSA-120 (paper version)2,1481273
SSA-120 (Internet version)1,1051337
Start Signature

Dated: September 16, 2014.

Faye Lipsky,

Reports Clearance Director, Social Security Administration.

End Signature End Preamble

[FR Doc. 2014-22341 Filed 9-18-14; 8:45 am]