Document Headings

                    Document headings vary by document type but may contain                    the following:                  
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###### Social Security Administration

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:**OIRA_Submission@omb.eop.gov*.                 

                    (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: OPLM.RCO@ssa.gov.*

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                           ( print 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.                           ( print 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