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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 new information collections, approval of existing information collections, 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, Attn: Desk Officer for SSA, Fax: 202-395-6974. 

(SSA), Social Security Administration, DCFAM, Attn: Reports Clearance Officer, 1333 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. Application for Widow's or Widower's Insurance Benefits—20 CFR 404.335-.338—0960-0004. SSA uses the information collected on the Form SSA-10-BK to determine if the applicant meets the statutory and regulatory conditions for entitlement to widow(er)'s benefits. The respondents are applicants for Widow(er)'s benefits. 

*Type of Request:*                     Extension of an OMB-approved information collection.                 

*Number of Respondents:*                     288,580.                 

*Frequency of Response:*                     1.                 

*Average Burden per Response:*                     15 minutes.                 

*Estimated Annual Burden:*                     72,145 hours.                 

2. Application for Parent's Insurance Benefits—20 CFR 404.370-404.374, 20 CFR 404.601-404.603—0960-0012. Form SSA-7-F6 collects information to entitle an individual to his parent's insurance benefits. The respondents are individuals who wish to apply to receive their parent's insurance benefits. 

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

*Number of Respondents:*                     1,400.                 

*Frequency of Response:*                     1.                 

*Average Burden per Response:*                     15 minutes.                 

*Estimated Annual Burden:*                     350 hours.                 

3. Statement of Marital Relationship (by One of the Parties)—20 CFR 404.726—0960-0038. SSA uses the information collected on Form SSA-754-F4 to determine whether the conditions for establishing a common-law marriage under State law are met. The respondents are applicants for spouse's benefits. 

*Type of Request:*                     Extension of an OMB-approved information collection.                 

*Number of Respondents:*                     30,000.                 

*Frequency of Response:*                     1.                 

*Average Burden per Response:*                     30 minutes.                 

*Estimated Annual Burden:*                     15,000 hours.                 

4. 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—0960-0662. The HA-1151 and HA-1152 are used to collect data that is required to determine the residual functional capacity (RFC) of individuals who are appealing denied claims for benefits based on disability. RFC must be determined to decide cases that cannot be decided based on current work activity or on medical facts alone. The respondents are medical sources who are paid by SSA to provide reports based either on existing medical evidence or on consultative examinations conducted for the purposes of the report. 

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

*Number of Respondents:*                     10,000.                 

*Frequency of Response:*                     20.                 

*Average Burden per Response:*                     15 minutes.                 

*Estimated Annual Burden:*                     50,000 hours.                 

5. SSI-Quality Review Case analysis—0960-0133. The form SSA-8508 is used in a personal interview with a sample of Supplemental Security Income (SSI) recipients and covers all elements of SSI eligibility. The information is used to assess the effectiveness of SSI policies and procedures and to determine payment accuracy rates. The respondents are SSI recipients. 

*Type of Request:*                     Extension of an OMB-approved information collection.                           ( print page 70651)    

*Number of Respondents:*                     3,900.                 

*Frequency of Response:*                     1.                 

*Average Burden per Response:*                     60 minutes.                 

*Estimated Annual Burden:*                     3,900 hours.                

6. Report of New Information in Disability Cases—20 CFR 404.460, 404.468, 404.408, 404.1588—0960-0071. The information collected on Form SSA-612 is used to update the disability records of respondents, based on changes reported. The form is used to gather information on a number of topics that can affect the beneficiary's or the applicant's entitlement to disability benefits. This includes, but is not limited to, information about a return to work, improvement in the medical condition, Workers' Compensation settlements or representative payee issues. The respondents are applicants for and recipients of Title II disability benefits. 

*Number of Respondents:*                     27,000.                 

*Frequency of Response:*                     1.                 

*Average Burden per Response:*                     5 minutes.                 

*Estimated Annual Burden:*                     2,250 hours.                 

7. Statement of Living Arrangements, In-Kind Support and Maintenance—20 CFR, 416.1130-.1148—0960-0174. Form SSA-8006 provides a national uniform vehicle for collecting information from SSI applicants and recipients about whether they receive income from in-kind support and maintenance. Responses are used to determine eligibility for SSI benefits. The respondents are individuals applying for SSI or whose eligibility is being reevaluated. 

*Type of Request:*                     Extension of an OMB-approved information collection.                 

*Number of Respondents:*                     173,380.                 

*Frequency of Response:*                     1.                 

*Average Burden per Response:*                     7 minutes.                 

*Estimated Annual Burden:*                     20,228 hours.                 

*Type of Request:*                     Extension of an OMB-approved information collection.                 

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. Supplement to Claim of Person Outside the United States—20 CFR 404.460, 404.463, 422.505(b), 42 CFR 407.27(c)—0960-0051. The information collected on Form SSA-21 is used to determine the continuing entitlement to Social Security benefits and the proper benefit amounts for alien beneficiaries living outside the United States. It is also used to determine whether benefits are subject to withholding tax. The respondents are individuals entitled to Social Security benefits who are, will be, or have been residing outside the United States. 

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

*Number of Respondents:*                     35,000.                 

*Frequency of Response:*                     1.                 

*Average Burden per Response:*                     10 minutes.                 

*Estimated Annual Burden:*                     5,833 hours.                 

2. Report on Individual with Mental Impairment—20 CFR 404.1513, 416.913—0960-0058. Form SSA-824 is used by SSA to determine the claimant's medical status prior to making a disability determination. The respondents are physicians, medical directors, medical record librarians and other health professionals. 

*Type of Request:*                     Extension of an OMB-approved information collection.                 

*Number of Respondents:*                     50,000.                 

*Frequency of Response:*                     1.                 

*Average Burden per Response:*                     36 minutes.                 

*Estimated Annual Burden:*                     30,000 hours.                 

3. Claimant's Work Background—20 CFR 404.1565(b), 416.965(b)—0960-0300. The information collected on Form HA-4633 is needed and used to afford claimants their statutory right to a hearing and decision under the Social Security Act. The information is used by SSA in cases in which claimants for disability benefits have requested a hearing on the determination regarding their claim. A completed form provides an updated summary of a claimant's past relevant work and helps the administrative law judge to better decide whether or not the claimant is disabled. The respondents are claimants requesting hearings for benefits based on disability under Titles II and/or XVI of the Act. 

*Type of Request:*                     Extension of an OMB-approved information collection.                 

*Number of Respondents:*                     120,000.                 

*Frequency of Response:*                     1.                 

*Average Burden per Response:*                     15 minutes.                 

*Estimated Annual Burden:*                     30,000 hours.                 

4. Coverage of Employees of State and Local Governments—20 CFR 404, Subpart M—0960-0425. States (and Interstate Instrumentalities) are required to provide wage information and deposit related contributions for pre-1987 periods to SSA. The regulations at 20 CFR 404, Subpart M set forth the rules for States submitting reports of deposits and related recordkeeping. The respondents are State and local governments or Interstate Instrumentalities. 

*Type of Request:*                     Extension of an OMB-approved information collection.                 

*Number of Respondents:*                     52.                 

*Frequency of Response:*                     1.                 

*Average Burden per Response:*                     1 hour.                 

*Estimated Annual Burden:*                     52 hours.                 

5. Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection; Medical Report on Child with Allegation of Human Immunodeficiency Virus (HIV) Infection—20 CFR 416.993-416.994—0960-0500. Collection of the information on Forms SSA-4814-F5 and SSA-4815-F6 is necessary for SSA to determine if an individual with HIV infection meets the requirements for presumptive disability (PD) payments. The SSA Field Office (FO) will mail the appropriate form to the claimant's medical source for completion and return to the FO. The FO staff will use the information on the form to determine if a PD is warranted. The respondents are the medical sources of applicants for SSI disability payments. 

*Type of Request:*                     Extension of an OMB-approved information collection.                 

*Number of Respondents:*                     59,100.                 

*Frequency of Response:*                     1.                 

*Average Burden per Response:*                     10 minutes.                

*Estimated Annual Burden:*                     9,850 hours.                 

6. SSI Notice of Interim Assistance Reimbursement (IAR)—0960-0546. Forms SSA-8125 and SSA-L8125-F6 are used by SSA to obtain the amount of Interim Assistance Reimbursement (IAR) a State is due before it can pay IAR to the State in various situations. When SSA releases the first retroactive SSI payment the SSA-8125 is filled out by the State for accounting and auditing purposes. The SSA-L8125-F6 is only used in cases when SSA must ensure that an IAR State does not send a residual IAR payment to a recipient who may be affected by the dedicated account and installment provision as set forth in Pub. Law 100-203. Respondents are State IAR officers. 

*Type of Request:*                     Extension of an OMB-approved information collection.                 

*Number of Respondents:*                     50,000.                 

*Frequency of Response:*                     1.                 

*Average Burden per Response:*                     10 minutes.                 

*Estimated Annual Burden:*                     8,333 hours.                 

                    III. The information collections listed below have been submitted to OMB for clearance. These notices have been                           ( print page 70652)                        previously published, and are being republished because changes have been made to the collections' burden estimates. 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. General Request for Social Security Records, eFOIA—20 CFR 402.130—0960-NEW. The eFOIA is a new electronic form that the public can use to request public information from the Agency. 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:*                     5,000.                 

*Frequency of Response:*                     1.                 

*Average Burden per Response:*                     3 minutes.                 

*Estimated Annual Burden:*                     250 hours.                 

2. Application to Collect a Fee for Payee Services—0960-NEW. Information requested on form SSA-445 will be used to determine whether the applicant meets the requirements to become a fee for service organizational payee, and if the applicant has provided all the information and documentation required. Based on the information provided on form SSA-445, SSA will issue a determination authorizing or denying permission to collect fees for payee services. The respondents are fee for payee service applicants. 

*Type of Request:*                     New information collection.                 

*Number of Respondents:*                     100.                 

*Frequency of Response:*                     1.                 

*Average Burden per Response:*                     10 minutes.                 

*Estimated Annual Burden:*                     17 hours.                 

Dated: November 15, 2005. 

Elizabeth A. Davidson, 

Reports Clearance Officer, Social Security Administration. 

[FR Doc. 05-22983 Filed 11-21-05; 8:45 am] 

BILLING CODE 4191-02-P