21618 Federal Register / Vol. 77, No. 69 / Tuesday, April 10, 2012 / Notices 

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 May 10, 2012. Individuals 

can obtain copies of the OMB clearance 

packages by calling the SSA Reports 

Clearance Director at 410–965–8783 or 

by writing to the above email address. 

Third Party Liability Information 

Statement—42 CFR 433.136–433.139— 

0960–0323. States may enter into 

agreements with the Commissioner of 

Social Security to make Medicaid 

eligibility determinations for aged, 

blind, and disabled beneficiaries in 

those states. Applications for and 

redeterminations of SSI eligibility in 

jurisdictions with such agreements are 

applications and redeterminations of 

Medicaid eligibility. 

To reduce Medicaid costs, Medicaid 

state agencies must identify third party 

insurers liable for medical care or 

services for Medicaid beneficiaries. 

Regulations at 42 CFR 433.136–433.139 

require Medicaid state agencies to 

obtain this information on Medicaid 

applications and redeterminations as a 

condition of Medicaid eligibility. The 

Medicaid state agencies use the 

information to bill third parties liable 

for medical care, support, or services for 

a beneficiary to guarantee that Medicaid 

remains the payer of last resort. Under 

the Medicaid agreements, SSA obtains 

third party liability information using 

Form SSA–8019, and provides that 

information to the Medicaid state 

agencies. The respondents are SSI 

claimants and recipients. 

Note: This is a correction notice: SSA 

published this information collection as an 

extension on January 31, 2012 at 77 FR 4854. 

Since we are revising the Privacy Act 

Statement, this is now a revision of an OMBapproved information collection. 

Type of Request: Revision of an OMBapproved information collection. 

Collection instrument Number of 

responses 

Frequency 

of response 

Average 

burden per 

response 

(minutes) 

Estimated 

total annual 

burden (hours) 

SSA–8012 Paper form ..................................................................................... 130 1 5 11 

Modernized SSI Claims System (MSSICS) ..................................................... 66,904 1 5 5,575 

Totals ........................................................................................................ 67,034 ........................ ........................ 5,586 

Dated: April 5, 2012. 

Faye Lipsky, 

Reports Clearance Director, Office of 

Regulations and Reports Clearance, Social 

Security Administration. 

[FR Doc. 2012–8546 Filed 4–9–12; 8:45 am] 

BILLING CODE 4191–02–P 

DEPARTMENT OF STATE 

[Public Notice 7843] 

60-Day Notice of Proposed Information 

Collection: Civilian Response Corps 

Database In-Processing Electronic 

Form, OMB Control Number 1405– 

0168, Form DS–4096 

ACTION: Notice of request for public 

comments. 

SUMMARY: The Department of State is 

seeking Office of Management and 

Budget (OMB) approval for the 

information collection described below. 

The purpose of this notice is to allow 60 

days for public comment in the Federal 

Register preceding submission to OMB. 

We are conducting this process in 

accordance with the Paperwork 

Reduction Act of 1995. 

• Title of Information Collection: 

Civilian Response Corps Database InProcessing Electronic Form. 

• OMB Control Number: 1405–0168. 

• Type of Request: Extension of a 

Currently Approved Collection. 

• Originating Office: Bureau of 

Conflict and Stabilization Operations 

(CSO). 

• Form Numbers: DS–4096. 

• Respondents: Individuals who are 

members of or apply for one or more of 

the three components of the Civilian 

Response Corps (Active, Standby and 

Expert Corps). 

• Estimated Number of Respondents: 

2000 per year. 

• Estimated Number of Responses: 

2000 per year. 

• Average Hours per Response: 1 

hour. 

• Total Estimated Burden: 2000 

Hours. 

• Frequency: On occasion. 

• Obligation to Respond: Required to 

receive benefits. 

DATE(S): The Department will accept 

comments from the public up to 60 days 

from April 10, 2012. 

ADDRESSES FOR COMMENTS AND FURTHER

INFORMATION: You may submit 

comments and request for further 

information by either of the following 

methods: 

• Email: CRCcomments@state.gov. 

• Mail (paper, disk, or CD–ROM 

submissions): CRC Comments, Suite 

1150, 1900 North Kent Street, Rosslyn, 

VA 22202. 

You must include the DS form 

number (if applicable), information 

collection title, and OMB control 

number in any correspondence. 

SUPPLEMENTARY INFORMATION: We are 

soliciting public comments to permit 

the Department to: 

• Evaluate whether the proposed 

information collection is necessary for 

the proper performance of our 

functions. 

• Evaluate the accuracy of our 

estimate of the burden of the proposed 

collection, including the validity of the 

methodology and assumptions used. 

• Enhance the quality, utility, and 

clarity of the information to be 

collected. 

• Minimize the reporting burden on 

those who are to respond, including the 

use of automated collection techniques 

or other forms of technology. 

Abstract of proposed collection: 

The information collected is an 

important part of the Department’s 

responsibility to coordinate U.S. 

Government planning; institutionalize 

U.S. conflict prevention and 

stabilization capacity; and help stabilize 

societies in transition from conflict or 

civil strife so they can reach a 

sustainable path toward peace, 

democracy, and a market economy. The 

information gathered will be used to 

identify Civilian Response Corps 

members who are available to 

participate in CRC missions. 

Methodology: 

Respondents will complete an 

electronic DS–4096 application via the 

Web site (www.crs.state.gov). 

Dated: March 30, 2012. 

John C. Roberts, 

Director of Civilian Response Operations, 

Office of the Coordinator for Reconstruction 

& Stabilization, Department of State. 

[FR Doc. 2012–8635 Filed 4–9–12; 8:45 am] 

BILLING CODE 4710–02–P 


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