[Federal Register Volume 74, Number 65 (Tuesday, April 7, 2009)]
[Notices]
[Pages 15808-15810]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E9-7453]


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SOCIAL SECURITY ADMINISTRATION


Agency Information Collection Activities: Proposed Request and 
Comment Request

    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 revisions and extensions of OMB-approved 
Information Collections and a new collection.
    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 the 
burden on respondents, including the use of automated collection 
techniques or other forms of information technology. Mail, e-mail, or 
fax your comments and recommendations on the information collection(s) 
to the OMB Desk Officer and the SSA Reports Clearance Officer to the 
addresses or fax numbers listed below.

(OMB), Office of Management and Budget. Attn: Desk Officer for SSA. 
Fax: 202-395-6974. E-mail Address: <a href="/cdn-cgi/l/email-protection#c08f8992819f93b5a2ada9b3b3a9afae80afada2eea5afb0eea7afb6"><span class="__cf_email__" data-cfemail="7a3533283b25290f18171309091315143a151718541f150a541d150c">[email protected]</span></a>.
(SSA), Social Security Administration, DCBFM, Attn: Reports Clearance 
Officer, 1332 Annex Building, 6401 Security Blvd., Baltimore, MD 21235. 
Fax: 410-965-6400. E-mail Address: <a href="/cdn-cgi/l/email-protection#703f203c3d5e22333f300303115e171f06"><span class="__cf_email__" data-cfemail="d29d829e9ffc80919d92a1a1b3fcb5bda4">[email protected]</span></a>.

    I. The information collection below is pending at SSA. SSA will 
submit it 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 June 
8, 2009. Individuals can obtain copies of the collection instrument by 
calling the SSA Reports Clearance Officer at 410-965-3758 or by writing 
to the e-mail address listed above.

1. Statement of Claimant or Other Person--20 CFR 404.702 & 416.570--
0960-0045

    SSA uses the SSA-795 to obtain information from claimants or other 
persons having knowledge of facts in connection with claims for 
Supplemental Security Income (SSI) or Social Security benefits when 
there is no standard form to collect the needed information. SSA then 
uses the information to process claims for benefits or for ongoing 
issues related to the above programs. The respondents are applicants/
recipients of SSI or Social Security benefits, or others who are in a 
position to provide information pertinent to the claim(s).
    Type of Request: Revision of an OMB-approved information 
collection.
    Number of Respondents: 305,500.
    Frequency of Response: 1.
    Average Burden per Response: 15 minutes.
    Estimated Annual Burden: 76,375 hours.

2. Statement of Employer--20 CFR 404.801-404.803--0960-0030

    SSA uses Form SSA-7011-F4 to substantiate allegations of wages paid 
to workers when those wages do not appear in SSA's records of earnings 
and the worker does not have proof of those earnings. SSA uses the 
information received on this form to process claims for Social Security 
benefits and to resolve discrepancies in the individual's Social 
Security earnings record. We only send Form SSA-7011-F4 to employers if 
we deem it necessary; in many situations, we are able to locate the 
earnings information within our records without having to contact the 
employer. The respondents are employers who can verify wage allegations 
made by wage earners.
    Type of Request: Extension of an OMB-approved information 
collection.
    Number of Respondents: 925,000.
    Frequency of Response: 1.
    Average Burden per Response: 20 minutes.
    Estimated Annual Burden: 308,333 hours.

3. Statement of Self-Employment Income--20 CFR 404.101, 404.110, 
404.1096(a)-(d)--0960-0046

    SSA collects the information on Form SSA-766 to expedite the 
payment of benefits to an individual who is self-employed and who is 
establishing insured status. The form elicits the information necessary 
to determine if the individual will have the minimum amount of self-
employment income for quarters of coverage. Respondents are

[[Page 15809]]

self-employed individuals who may be eligible for Social Security 
benefits.
    Type of Request: Extension of an OMB-approved information 
collection.
    Number of Respondents: 2,500.
    Frequency of Response: 1.
    Average Burden per Response: 5 minutes.
    Estimated Annual Burden: 208 hours.

4. Certification by Religious Group--20 CFR 404.1075--0960-0093

    SSA uses Form SSA-1458 to determine whether a religious group meets 
the qualifications set out in Section 1402(g) of the Internal Revenue 
Code, which exempts members of certain religious groups and sects from 
payment of Self-Employment Contribution Act taxes. The respondents are 
spokespersons for religious groups or sects.
    Type of Request: Extension of an OMB-approved information 
collection.
    Number of Respondents: 180.
    Frequency of Response: 1.
    Average Burden per Response: 15 minutes.
    Estimated Annual Burden: 45 hours.

5. Claim for Amounts Due in the Case of a Deceased Beneficiary--20 CFR 
404.503(b)--0960-0101

    A completed SSA-1724 ensures proper payment of an underpayment due 
a deceased beneficiary. It is required when there is insufficient 
information in the file to identify the person(s) entitled to the 
underpayment, or the person's address. Generally, SSA collects the 
information when a surviving widow(er) is not already entitled to a 
monthly benefit on the same earnings record, or is not filing for a 
lump-sum death payment as a living-with spouse. The respondents are 
applicants for underpayments owed to deceased beneficiaries.
    Type of Request: Revision of an OMB-approved information 
collection.
    Number of Respondents: 450,000.
    Frequency of Response: 1.
    Average Burden per Response: 10 minutes.
    Estimated Annual Burden: 75,000 hours.

6. Instructions for Completion of Federal Assistance Application--0960-
0184

    SSA uses information from Form SSA-BK-96 in selecting grant 
proposals for funding based on their technical merits. This information 
assists the agency in evaluating the soundness of the design of the 
proposed activities, the possibility of obtaining productive results, 
the adequacy of resources to conduct the activities, and the 
relationship to other similar activities of the respondents. The 
respondents are State and local governments, state-designated 
protection and advocacy groups, colleges and universities, and profit 
and nonprofit private organizations.
    Type of Request: Extension of an OMB-approved information 
collection.
    Number of Respondents: 400.
    Frequency of Response: 2.
    Average Burden per Response: 14 hours.
    Estimated Annual Burden: 11,200 hours.

7. Request for Deceased Individual's Social Security Record--20 CFR 
402.130--0960-0665

    SSA uses the Form SSA-711 to process requests from the public for a 
microprint of the SS-5, Application for Social Security Card, for a 
deceased individual. Respondents are members of the public who are 
requesting deceased individuals' Social Security records.
    Type of Request: Extension of an OMB-approved information 
collection.
    Number of Respondents: 50,000.
    Frequency of Response: 1.
    Average Burden per Response: 7 minutes.
    Estimated Annual Burden: 5,833 hours.

8. Electronic Records Express--0960-0753

    Electronic Records Express (ERE) is a Web-based SSA program that 
allows medical providers to submit disability claimant data 
electronically to SSA. Both medical providers and other third parties 
with connections to disability applicants/recipients can use this 
system. This information collection request (ICR) includes the 
registration process for becoming a certified ERE user. We are 
expanding this ICR to include increased functionality for ERE by giving 
medical providers the ability to submit invoices electronically. The 
respondents are medical providers who evaluate or treat disability 
claimants/recipients and are ERE users.
    Type of Request: Revision of an OMB-approved information 
collection.
    Number of Respondents: 17,689.
    Frequency of Response: 1.
    Average Burden per Response: 10 minutes.
    Estimated Annual Burden: 2,948 hours.
    II. SSA has submitted the information collections listed below to 
OMB for clearance. Your comments on the information collections 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 7, 2009. You can obtain a copy of the 
OMB clearance packages by calling the SSA Reports Officer at 410-965-
3758 or by writing to the above listed address.

1. 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 to handle his or her own SSI or Social Security 
benefits. This information assists SSA in determining the need for a 
representative payee. The respondents are physicians of the 
beneficiaries' or medical officers of the institution where the 
beneficiaries reside.

    Note: This is a correction notice. SSA published this 
information collection as an extension on January 15, 2009 at 74 FR 
2642. Since we are revising the Privacy Act Statement, this is now a 
revision of an OMB-approved information collection.

    Type of Request: Revision of an OMB-approved information 
collection.
    Number of Respondents: 24,000.
    Frequency of Response: 1.
    Average Burden per Response: 15 minutes.
    Estimated Annual Burden: 6,000 hours.

2. QuickStart Automated Enrollment System--31 CFR 210--0960-0564

    Financial institutions (FI) collect Direct Deposit (DD)/Electronic 
Funds Transfer (EFT) information from their depositors who are 
enrolling for the first time, or who are changing DD/EFT information. 
The Department of Treasury's Green Book, which is available online, 
includes information needed to enroll under QuickStart. The Green Book 
provides the data elements the recipient completes to enroll in direct 
deposit. Since the FI submits the DD/EFT information electronically, it 
is not using a SSA-prescribed form for sending information to 
Government agencies. SSA collects this information to facilitate 
electronic payments of funds. The respondents are Social Security and 
SSI recipients, and their FIs.
    Type of Request: Extension of an OMB-approved information 
collection.
    Number of Respondents: 3,950,000.
    Frequency of Response: 1.
    Average Burden per Response: 3 minutes.
    Estimated Annual Burden: 197,500 hours.

[[Page 15810]]

3. Certification of Low Birth Weight--20 CFR 416.931, 416.926a(m), and 
416.924--0960-0720

    Hospitals and claimants use Form SSA-3380 to provide medical 
information to local field offices (FO) and the Disability 
Determination Services (DDS) on behalf of infants with low birth 
weight. FOs use the form as a protective filing statement and the 
medical information to make presumptive disability findings, which 
allow expedited payment to eligible claimants. DDSs use the medical 
information to determine disability and continuing disability. The 
respondents are hospitals that have information identifying low birth 
weight babies and their medical conditions.

    Note: This is a correction notice. SSA published this 
information collection as an extension on January 15, 2009 at 74 FR 
2643. Since we are revising the Privacy Act Statement, this is now a 
revision of an OMB-approved information collection.

    Type of Request: Revision of an OMB-approved information 
collection.
    Number of Respondents: 24,000.
    Frequency of Response: 1.
    Average Burden per Response: 15 minutes.
    Estimated Annual Burden: 6,000 hours.

4. Letter to Employer Requesting Information about Wages Earned by 
Beneficiary--20 CFR 416.703 & 404.801--0960-0034

    When SSA has incomplete or questionable wage data, SSA uses Form 
SSA-L725 to verify a beneficiary's wages. SSA uses the information on 
the SSA-L725 to calculate the correct benefits payable and to maintain 
an accurate record of earnings for the beneficiary. Respondents are 
small business employers.
    Type of Request: Extension of an OMB-approved information 
collection.
    Number of Respondents: 150,000.
    Frequency of Response: 1.
    Average Burden per Response: 40 minutes.
    Estimated Annual Burden: 100,000 hours.

5. Statement of Care and Responsibility for Beneficiary--20 CFR 
404.2020, 404.2025, 408.620, 408.625, 416.620, 416.625--0960-0109

    SSA uses information from Form SSA-788 to verify statements of 
concern made by payee applicants and to identify other potential 
payees. SSA is concerned with selecting the most qualified 
representative payee who will use Social Security benefits in the 
beneficiary's best interest. SSA considers factors such as the payee 
applicant's capacity to perform payee duties, awareness of the 
beneficiary's situation and needs, demonstration of past and current 
concern for the beneficiary's well-being. If the payee applicant does 
not have custody of the beneficiary, SSA will obtain information from 
the custodian to evaluate against information provided by the 
applicant. Respondents are individuals who have custody of the 
beneficiary in cases where someone else has filed to be the 
beneficiary's representative payee.
    Type of Request: Revision of an OMB-approved information 
collection.
    Number of Respondents: 130,000.
    Frequency of Response: 1.
    Average Burden per Response: 10 minutes.
    Estimated Annual Burden: 21,667 hours.

6. Third Party Liability Information Statement--42 CFR 433.136-
433.139--0960-0323

    Medicaid state agencies must identify third party insurers liable 
for medical care or services for Medicaid beneficiaries; this reduces 
Medicaid costs. 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. 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. Under these agreements, 
SSA obtains third party liability information using Form SSA-8019 and 
provides that information to the Medicaid state agencies. 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. The respondents are SSI 
claimants and recipients.
    Type of Request: Revision of an OMB-approved information 
collection.
    Number of Respondents: 62,834.
    Frequency of Response: 1.
    Average Burden per Response: 5 minutes.
    Estimated Annual Burden: 5,236 hours.

7. Application for Special Age 72-or-Over Monthly Payments--20 CFR 
404.380-404.384--0960-0096

    Form SSA-19-F6 collects the information needed to determine whether 
a claimant can qualify for Special Age 72 payments. SSA will evaluate 
eligibility requirements using the data collected on this form. The 
respondents are individuals who reached age 72 before 1972.
    Type of Request: Revision of an OMB-approved information 
collection.
    Number of Respondents: 10.
    Frequency of Response: 1.
    Average Burden per Response: 10 minutes.
    Estimated Annual Burden: 2 hours.

    Dated: March 30, 2009.
John Biles,
Reports Clearance Officer, Center for Reports Clearance, Social 
Security Administration.
[FR Doc. E9-7453 Filed 4-6-09; 8:45 am]
BILLING CODE 4191-02-P


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