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 Social Security Administration
 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 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, 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. Quarterly Statistical Report on Recipients and Payments Under State-Administered Assistance Programs for 
                    ( print page 71864)
                    Aged, Blind and Disabled (Individuals and Couples) Recipients—20 CFR 416.2010, 20 CFR 416.2098—0960-0130. The purpose of the statistical report is to obtain State data on expenditures and caseloads of State-administered supplementation under the Supplemental Security Income (SSI) program. The statistics are needed to complement information available for the federally administered programs and to more fully explain the impact of the public income support programs on the needy, aged, blind, and disabled. In addition, the expenditure data are used to monitor State compliance with the mandatory pass-along provision. States use our publications, which are prepared from data submitted on this statistical report, for administrative purposes to compare their expenditures and caseloads with those of other States, to determine the feasibility of program change, and to keep abreast of program developments in other States. Federal personnel request data about State-administered supplementation programs to compare various State programs, to examine the relationship of State supplementation expenditures and caseloads to federally financed programs such as Medicaid, and to determine the effect of changes in SSI and other Federal programs on State supplementation programs. In addition, Federal and State personnel have used data obtained from this report in developing legislative proposals and budget estimates. *Type of Request:*
                     Extension of an OMB-approved information collection. *Number of Respondents:*
                     31. *Frequency of Response:*
                     4. *Average Burden Per Response:*
                     60 minutes. *Estimated Annual Burden:*
                     124 hours. 2. Application for Survivors Benefits—20 CFR 404.611 (a) and (c)—0960-0062. The information collected by form SSA-24 is needed to satisfy the “Joint Prescribed Application” of Title 38 U.S.C. 5105. That provision requires that survivors who file with either SSA or the Veteran's Administration (VA) shall be deemed to have filed with both agencies, and that each agency's forms must request sufficient information to constitute an application for both SSA and VA benefits. The respondents are survivors of members or former members of the armed services. When form SSA-24 is received by SSA from the VA, an earnings record is requested to determine if insured status exists so that the claimant will complete the appropriate SSA survivor application. If entitlement does not exist, SSA may disallow the claim. If an SSA survivor application has already been filed, form SSA-24 is treated as a duplicate application. *Type of Request:*
                     Extension of an OMB-approved information collection. *Number of Respondents:*
                     3,200. *Frequency of Response:*
                     1. *Average Burden Per Response:*
                     15 minutes. *Estimated Annual Burden:*
                     800 hours. 3. Continuing Disability Review Report—20 CFR 404.1589, 20 CFR 416.989—0960-0072. We use form SSA-454-BK to collect information from individuals receiving disability benefits or their representatives. We evaluate the information to determine whether the individuals remain eligible for benefit payments. Adults are considered eligible for payment if they continue to be unable to do substantial gainful activity (SGA) by reason of their impairments. Title XVI children are considered eligible for payment if they still have marked and severe functional limitations by reason of their impairments. We obtain information concerning sources of medical treatment, participation in vocational rehabilitation programs (if any), attempts to work (if any), and the opinions of individuals regarding whether their conditions have improved. *Type of Request:*
                     Revision of an OMB-approved information collection. *Number of Respondents:*
                     792,020. *Frequency of Response:*
                     1. *Average Burden Per Response:*
                     45 minutes. *Estimated Annual Burden:*
                     594,015 hours. 4. Statement Regarding Marriage—20 CFR 404.726—0960-0017. Form SSA-753 elicits information from third parties to verify the applicant's statement about intent, cohabitation, and holding out to the public as married, which are basic tenets of a common-law marriage. The responses are used by SSA to determine if a valid marital relationship exists and to make an accurate determination regarding entitlement to spouse/widow(er) benefits. The respondents are individuals who are familiar with and can provide confirmation of an applicant's common-law marriage. *Type of Request:*
                     Extension of an OMB-approved information collection. *Number of Respondents:*
                     40,000. *Frequency of Response:*
                     1. *Average Burden Per Response:*
                     9 minutes. *Estimated Annual Burden:*
                     6,000 hours. 5. Advance Notice of Termination of Child's Benefits and Student's Statement Regarding School Attendance—20 CFR 404.350-404.352, 404.367-404.368—0960-0105. The information collected on form SSA-1372 is needed to determine whether children of an insured worker are eligible for student benefits. The data allows SSA to determine student entitlement and whether entitlement will end. The respondents are student claimants for Social Security benefits, their respective schools and, in some cases, their payees. *Type of Request:*
                     Revision of an OMB-approved information collection. *Number of Respondents:*
                     200,000. *Frequency of Response:*
                     1. *Average Burden Per Response:*
                     10 minutes. *Estimated Average Burden:*
                     33,333 hours. 6. Request for Address Information From Motor Vehicles Records; Request for Address Information From Employment Commissions Records—4 CFR 104.2 —0960-0341. SSA sends form SSA-L711 to State Motor Vehicle Administrations to obtain the last known address from driver's license and registration records. SSA sends form SSA-L712 to State Employment Commissions to obtain the last known address from State unemployment/employment wage records. SSA uses the information to locate debtors to arrange for payment of debts owed to SSA. The respondents are State Motor Vehicle Administrations and State Employment Commissions. *Type of Request:*
                     Extension of an OMB-approved information collection. *Number of Respondents:*
                     2,400. *Frequency of Response:*
                     1. *Average Burden Per Response:*
                     2 minutes. *Estimated Average Burden:*
                     80 hours. 7.General Request for Social Security Records, eFOIA—20 CFR 402.130 —0960-NEW. SSA uses the information collected on this electronic request for Social Security records to respond to the public's request for information under the rights provided by the Freedom of Information Act (FOIA), and to track those requests by amount received, type of request, fees charged and responses sent within the required 20 days. Respondents are individuals or agencies requesting documents under FOIA. *Type of Request:*
                     New information collection. *Number of Respondents:*
                     300,000. *Frequency of Response:*
                     1. *Average Burden Per Response:*
                     3 minutes. *Estimated Annual Burden:*
                     15,000 hours. 8. Social Security Number Verification Service (SSNVS)—0960-0660 
                    ( print page 71865) Background Under Internal Revenue Service regulations, employers are obligated to provide wage and tax data to SSA using form W-2, Wage and Tax Statement or its electronic equivalent. As part of this process, the employer must furnish the employee's name and their Social Security Number (SSN). This information must match SSA's records in order for the employee's wage and tax data to be properly posted to their Earnings Record. Information that is incorrectly provided to the Agency must be corrected by the employer using an amended reporting form, which is a labor-intensive and time-consuming process for both SSA and the employer. Therefore, to help ensure that employers provide accurate name and SSN information, SSA piloted SSNVS with 100 employers and now plans to implement the service nationally. SSNVS Collection SSNVS is an optional free and secure Internet service for employers that allows them to perform advance verification of their employees' name and SSN information against SSA records. SSA will use the information collected through the SSNVS to verify that employee name and SSN information, provided by employers, matches SSA records. SSA will respond to the employer informing them only of matches and mismatches of submitted information. Respondents are employers who provide wage and tax data to SSA and elected to use the service. *Type of Request:*
                     Revision of an OMB-approved information collection. *Number of Respondents:*
                     200,000. *Frequency of Response:*
                     120. *Average Burden Per Response:*
                     5 minutes. *Estimated Annual Burden:*
                     2,000,000 hours. 9. Report of Death by Funeral Director—20 CFR 404.715, 404.720, 416.635—0960-0142. SSA uses the information on form SSA-721 to make timely and accurate decisions based on the report of death including: (1) proving the death of an insured individual, (2) learning of the death of a beneficiary whose benefits should terminate, and (3) determining who is eligible for the Lump-Sum Death Payment (LSDP) or may be eligible for benefits. The respondents are funeral directors with knowledge of the fact of death. *Type of Request:*
                     Extension of an OMB-approved information collection. *Number of Respondents:*
                     741,113. *Frequency of Response:*
                     1. *Average Burden Per Response:*
                     3.5 minutes. *Estimated Annual Burden:*
                     43,231 hours. 10. Application for SSI—20 CFR 416.305-335—0960-0229. SSA uses the information collected on form SSA-8000-BK or its electronic equivalent, the Modernized SSI Claims System (MSSICS), to determine eligibility for SSI and the amount of benefits payable to the applicant. During the personal interview process the MSSICS system takes less time to complete because the system propagates like information and only asks relevant questions of the applicant. Approximately 97% of SSI applications are taken via MSSICS. The respondents are applicants for SSI payments. *Type of Request:*
                     Revision of an OMB-approved information collection. Form SSA-8000 *Number of Respondents:*
                     33,851. *Frequency of Response:*
                     1. *Average Burden Per Response:*
                     41 minutes. *Estimated Annual Burden:*
                     23,132 hours. MSSICS *Number of Respondents:*
                     1,094,523. *Frequency of Response:*
                     1. *Average Burden Per Response:*
                     36 minutes. *Estimated Annual Burden:*
                     656,714 hours. *Total Burden Hours:*
                     679,846. II. The information collections listed below have 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 packages by calling the SSA Reports Clearance Officer at 410-965-0454, or by writing to the address listed above. 1. Work Activity Report (Self-Employed)—20 CFR 404.1520(b) 20 CFR 1571-.1576 20 CFR 404.1584-.1593 20 CFR 416.971-.976—0960-0598. The information on form SSA-820-F4 is used by SSA to determine initial or continuing eligibility for SSI or Social Security disability benefits. Under Title II and Title XVI of the Act, applicants for disability benefits must prove an inability to perform any kind of substantial gainful activity (SGA) generally available in the national economy for which they might be expected to qualify on the basis of age, education, and work experience. SSA needs to secure information about this work in order to ascertain whether the applicant was (or is) engaging in SGA. Work after a claimant becomes entitled can cause the cessation of disability benefits. The information obtained from form SSA-820-F4 is needed to determine if a cessation of benefits should occur. *Type of Request:*
                     Extension of an OMB-approved information collection. *Number of Respondents:*
                     100,000. *Frequency of Response:*
                     1. *Average Burden Per Response:*
                     30 minutes. *Estimated Annual Burden:*
                     50,000 hours. 2. Cessation or Continuance of Disability or Blindness Determination—20 CFR 404.1615-20 CFR 404.1512-20 CFR 404.1588-1599—0960-0443. The information on form SSA-832-U3/C3 is used by SSA to document determinations as to whether an individual's disability benefits should be terminated or continued on the basis of his/her impairment. The respondents are State Disability Determination Services (DDS) employees adjudicating Title XVI disability claims. *Type of Request:*
                     Extension of an OMB-approved information collection. *Number of Respondents:*
                     392,191. *Frequency of Response:*
                     1. *Average Burden Per Response:*
                     30 minutes. *Estimated Annual Burden:*
                     196,096 hours. 3. Representative Payee Report—20 CFR 404.2035, 404.2065, 416.635, and 416.665—0960-0068. The information on forms SSA-623 and SSA-6230 is used by SSA to determine whether payments certified to a representative payee have been used for the beneficiary's current maintenance and personal needs and to determine whether the representative payee continues to be concerned with the beneficiary's welfare. The respondents are representative payees. *Type of Request:*
                     Extension of an OMB-approved information collection. *Number of Respondents:*
                     5,250,000. *Frequency of Response:*
                     1. *Average Burden Per Response:*
                     15 minutes. *Estimated Annual Burden:*
                     1,312,500 hours. 4. Modified Benefit Formula Questionnaire—0960-0395. SSA uses the information collected by form SSA-150 to determine the correct formula to be used in computing the Social Security benefit for someone who receives a pension from employment not covered by Social Security. The Windfall Elimination Provision (WEP) requires use of a benefit formula that replaces a smaller percentage of a worker's pre-retirement earnings. However, the difference in the benefit computed using the modified and regular formulas cannot be greater than 
                    ( print page 71866)
                    one-half the amount of the pension received in the first month an individual is entitled to both the pension and the Social Security benefit. Form SSA-150 collects the information needed to make all the necessary benefit computations. The respondents are claimants for Social Security benefits who are entitled to both benefits. *Type of Request:*
                     Extension of an OMB-approved information collection. *Number of Respondents:*
                     90,000. *Frequency of Response:*
                     1. *Average Burden Per Response:*
                     8 minutes. *Estimated Average Burden:*
                     12,000 hours. 5. Modified Benefit Formula Questionnaire-Employer—0960-0477. The information collected on form SSA-58 is used by SSA to verify the claimant's allegations on form SSA-150 (OMB #0960-0395). SSA must make a determination regarding whether the modified benefit formula is applicable and when to first apply it to a person's benefit. This form will be sent to an employer for pension-related information if the claimant is unable to provide it. The respondents are people who are eligible after 1985 for both Social Security benefits and a pension based on work not covered by SSA. *Type of Request:*
                     Extension of an OMB-approved information collection. *Number of Respondents:*
                     30,000. *Frequency of Response:*
                     1. *Average Burden Per Response:*
                     20 minutes. *Estimated Average Burden:*
                     10,000 hours. 6. Acknowledgement of Receipt (Notice of Hearing)—part 404, subpart  J, 404.936(d), (e) and (f); 404.938(c); 404.950(a); part 416, subpart N, 416.1436(d), (e) and (f); 416.1438(c); 416.1450(a)—0960-0671. The information collected under 20 CFR 404.938(c) and 416.1438(c) through form HA-504 is used by SSA to process requests for hearings on unfavorable determinations of entitlement or eligibility to disability payments. SSA needs the information to determine if the individual received the notice of hearing issued by an Administrative Law Judge (ALJ) and whether the individual intends to appear at the scheduled time and place. The respondents are applicants for Social Security and SSI disability payments who want to have a hearing to appeal an unfavorable decision. Information collected under 20 CFR 404.936(d), (e) and (f) and 416.1436(d), (e) and (f) (not on a prescribed form, but in writing, if possible) is used to determine if the individual objects to the scheduled time and place for his or her hearing and, if so, the individual's reasons for objecting and the time and place he or she would like to have the hearing held. Documentary evidence that a party presents at his or her hearing under 20 CFR 404.950(a) and 416.1450(a) is used in deciding if the individual qualifies for benefits. For those collections cleared through SSA forms, the public reporting burden is accounted for in the ICRs for the various forms. Consequently, a 1-hour placeholder burden is being assigned to the specific reporting requirements contained in the rule. Section
Annual 
                             number of  
                             responses
Frequency of response
Average 
                             burden per  
                             response  
                             (minutes)
Estimated 
                             annual burden (hours)404.936(d), (e) & (f)
92,000
1
10
15,333404.938(c) & 416.1438(c)-HA-504
550,000
1
1
9,166404.950(a)
210,000
1
30
105,000416.1436(d), (e) & (f)
75,000
1
10
12,500416.1450(a)
172,000
1
30
86,000Total
1,099,000


227,999
 *Type of Request:*
                     Extension of an OMB-approved information collection. 7. State Death Match—20 CFR 404.301, 20 CFR 404.310-311, 20 CFR 404.316, 20 CFR 404.330-341, 20 CFR 404.350-352, 20 CFR 404.371, and 20 CFR 416.912—0960-NEW. Background Section 205(r) of the Social Security Act requires SSA to contract with the States to obtain death certificate information in order to compare it to SSA's payment files. This match ensures the accuracy of our payment files by detecting unreported or inaccurate deaths of beneficiaries. Entitlement to retirement, disability, wife's, husband's or parent's benefits under the provisions of the Social Security Act terminates when the beneficiary dies. About 2.5 million people die in the United States each year. Approximately 2.0 million are SSA beneficiaries. Therefore, the information is instrumental in maintaining payment integrity. SSA is seeking clearance of both the current state death match reporting process and the new Web-based Electronic Death Registration (EDR) process described below: State Death Match—Current Process The first participants in the death registration process, usually funeral directors, are charged by State law to complete the demographic information on the decedent and obtain necessary physicians' signatures to complete the death registration. Once the death registration information is completed, the first participant sends the information to the State's bureau of vital statistics (SBVS). The SBVS officially registers the death and is the official keeper of the death record. Each State then furnishes this information to SSA, using current technology including Vital Information Systems Network (VISN), electronic Vital Information Systems Network (eVISN), and ConnectDirect. Under this process SSA must independently verify the State death data before taking a termination action. The respondents are the SBVS. State Death Match—EDR Online Verification of the SSN in State Death Registration Process The States are now updating and further automating the death registration processes. This State reengineering effort is widely known as the EDR initiative. The EDR system permits electronic transfer of the death certificate. Under EDR the first participant completes a portion and electronically sends the document to the next participant for completion and submission to the SBVS. An additional feature of EDR is the Online Verification System (OVS) developed by the National Association for Public Health Statistics and Information System (NAPHSIS) in conjunction with SSA. The process allows the first participants in the death registration process to enter the 
                    ( print page 71867)
                    decedent's demographic information including the SSN into the EDR system. The system will verify the SSN online in real time and creates an electronic death certificate as well as a fact of death report. The States have agreed that the on-line verification of the SSN at the first point of collection in the registration process will satisfy the requirement to independently verify the SSN. EDR reduces the processing time needed to register deaths and greatly improves the business practices of the various participants in death registration process. EDR will result in the State's ability to send SSA the report with a verified SSN within 5 days of the date of death and within 24 hours of receipt in the State repository. SSA is using a phased-in approach to EDR. When fully implemented, SSA will save significant program dollars and work years annually. The respondents are the SBVS. *Type of Request:*
                     New information collection. *Estimated Annual Cost for all respondents:* Collection format
Number of 
                             respondents
Frequency of responses 
                             (per state)
Average cost per record 
                             request
Estimated 
                             annual cost  
                             burdenState Death Match—Current Registration process
52
50,000
$.67
**$1,742,000**State Death Match—Electronic Death Registration (EDR)
3
50,000
2.48
372,000
 Please note that both of these data matching processes are entirely electronic and there is no hourly burden for the respondent to provide this information. III. Agency Information Collection Activities: Emergency Consideration Request. In compliance with Public Law 104-13, the Paperwork Reduction Act of 1995, SSA is providing notice that it is submitting to OMB information collections for emergency consideration. SSA is revising these forms as a result of the Social Security Protection Act of 2004. SSA is requesting emergency consideration from OMB by January 10, 2005 of the information collections listed below. Therefore, comments should be submitted to OMB and SSA by that date. 1. Petition To Obtain Approval Of A Fee For Representing A Claimant Before the Social Security Administration—20 CFR Subpart R, 404.1720, 404.1725; Subpart F, 410.686b; Subpart O, 416.1520 and 416.1525—0960-0104. A representative of a claimant for Social Security benefits must file either a fee petition or a fee agreement with SSA in order to charge a fee for representing a claimant in proceedings before SSA. The representative uses form SSA-1560-U4 to petition SSA for authorization to charge and collect a fee. A claimant may also use the form to agree or disagree with the requested fee amount or other information the representative provides on the form. SSA uses the information to determine a reasonable fee that a representative may charge and collect for his or her services. The respondents are claimants, their attorneys and other persons representing them. *Type of Request:*
                     Emergency. *Number of Respondents:*
                     34,624. *Frequency of Response:*
                     1. *Average Burden Per Response:*
                     30 minutes. *Estimated Annual Burden:*
                     17,312 hours. 2. Appointment of Representation—20 CFR 404.1707, 404.1720, 404.1725, 410.684 and 416.1507—0960-0527. The information collected by SSA on form SSA-1696-U4 is used to verify the applicant's appointment of a representative. It allows SSA to inform the representative of items which affect the applicant's claim. The affected public consists of applicants who notify SSA that they have appointed a person to represent them in their dealings with SSA when claiming a right to benefits. *Type of Request:*
                     Emergency. *Number of Respondents:*
                     551,520. *Frequency of Response:*
                     1. *Average Burden Per Response:*
                     10 minutes. *Estimated Annual Burden:*
                     91,920 hours. Dated: December 3, 2004. Elizabeth A. Davidson, Reports Clearance Officer, Social Security Administration.


[FR Doc. 04-26998 Filed 12-9-04; 8:45 am] BILLING CODE 4191-02-P