[Federal Register Volume 69, Number 65 (Monday, April 5, 2004)]
[Notices]
[Pages 17725-17728]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 04-7535]


=======================================================================
-----------------------------------------------------------------------

SOCIAL SECURITY ADMINISTRATION


Agency Information Collection Activities: Proposed Request and 
Comment Request

    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

[[Page 17726]]

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, New 
Executive Building, Room 10235, 725 17th St., NW., Washington, DC 
20503, 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. Request for Waiver of Overpayment Recovery or Change in 
Repayment Notice--20 CFR 404.502-404.515 and 20 CFR 416.550-416.570--
0960-0037. Form SSA-632 collects information on the circumstances 
surrounding overpayment of Social Security Benefits to recipients. SSA 
uses the information to determine whether recovery of an overpayment 
amount can be waived or must be repaid and, if repaid, how recovery 
will be made. The respondents are recipients of Social Security, 
Medicare or Supplemental Security Income (SSI) overpayments.
    Type of Request: Extension of OMB-approved information collection.
    Number of Respondents: 500,000.
    Frequency of Response: 1.
    Average Burden Per Response: 120 minutes.
    Estimated Annual Burden: 1,000,000 hours.
    2. Requests for Self-Employment Information, Employee Information, 
Employer Information--20 CFR, Subpart A, 422.120--0960-0508. SSA uses 
Forms SSA-L2765, SSA-L3365 and SSA-L4002 to request correct information 
when an employer, employee or self-employed person reports an 
individual's earnings without a Social Security Number (SSN) or with an 
incorrect name or SSN. The respondents are employers, employees or 
self-employed individuals who are requested to furnish additional 
identifying information.
    Type of Request: Revision of an OMB-approved information 
collection.
    Number of Respondents: 3,000,000.
    Frequency of Response: 1.
    Average Burden Per Response: 10 minutes.
    Estimated Annual Burden: 500,000 hours.
    3. Disability Hearing Officer's Decision--20 CFR 404.917 and 
416.1417--0960-0441. The Social Security Act requires that SSA provide 
an evidentiary hearing at the reconsideration level of appeal for 
claimants who have received an initial or revised determination that a 
disability did not exist or has ceased. Based on the hearing, the 
disability hearing officer (DHO) completes form SSA-1207 and all 
applicable supplementary forms (which vary depending on the type of 
claim). The DHO uses the information in documenting and preparing the 
disability decision. The form will aid the DHO in addressing the 
crucial elements of the case in a sequential and logical fashion. The 
respondents are DHOs in the State Disability Determination Services 
(DDS).
    Type of Request: Extension of an OMB-approved information 
collection.
    Number of Respondents: 65,000.
    Frequency of Response: 1.
    Average Burden Per Response: 45 minutes.
    Estimated Annual Burden: 48,750 hours.
    4. Real Property Current Market Value Estimate--0960-0471. The form 
SSA-L2794 is used to obtain current market value estimates of real 
property owned by applicants for, or beneficiaries of, SSI payments (or 
a person whose resources are deemed to such an individual). The value 
of an individual's resources, including non-home real property, is one 
of the eligibility requirements for SSI recipients. The respondents are 
individuals with knowledge of local real property values.
    Type of Request: Extension of an OMB-approved information 
collection.
    Number of Respondents: 5,438.
    Frequency of Response: 1.
    Average Burden Per Response: 20 minutes.
    Estimated Annual Burden: 1,813 hours.
    5. Function Report--Child: Birth to 1st Birthday (SSA-3375), Age 1 
to 3rd Birthday (SSA-3376), Age 3 to 6th Birthday (SSA-3377), Age 6 to 
12th Birthday (SSA-3378), and Age 12 to 18th Birthday (SSA-3379)--20 
CFR 416.912--0960-0542. State Agency adjudicative teams use the 
information gathered by these forms in combination with other medical 
function evidence to form a complete picture of a child's ability to 
function. This information is used to help determine if a child is 
disabled, especially in cases in which disability cannot be found on 
medical grounds alone. The respondents are applicants for Title XVI 
childhood disability benefits and their caregivers.
    Type of Request: Extension of an OMB-approved information 
collection.
    Number of Respondents: 650,000
    Frequency of Response: 1.
    Average Burden Per Response: 20 minutes.
    Estimated Annual Burden: 216,667 hours.
    6. Function Report--Third Party--20 CFR 404.1512 and 416.912--0960-
0635. The Social Security Act requires claimants to provide medical and 
other evidence to prove they are disabled. The Act also gives the 
Commissioner of Social Security the authority to make rules and 
regulations about the nature and extent of the evidence required to 
prove disability as well as the methods of obtaining this evidence. The 
information collected from form SSA-3380 is needed to determine 
disability under Title II (Old-Age, Survivors and Disability Insurance 
(OASDI) and/or Title XVI (SSI). The form records information about the 
disability applicant's illnesses, injuries, conditions, impairment-
related limitations, and ability to function. The respondents are 
individuals who are familiar with the applicant's disability, 
impairment, limitations, and ability to function.
    Type of Request: Revision of an OMB-approved information 
collection.
    Number of Respondents: 1,500,000.
    Frequency of Response: 1.
    Average Burden Per Response: 30 minutes.
    Estimated Annual Burden: 750,000 hours.
    7. Application for Benefits Under the Italy-U.S. International 
Social Security Agreement--0960-0445--20 CFR 404.1925. The information 
collected on Form SSA-2528 is required by SSA in order to determine 
entitlement to benefits. The respondents are applicants for old-age, 
survivors or disability benefits, who reside in Italy.

[[Page 17727]]

    Type of Request: Extension of an OMB-approved information 
collection.
    Number of Respondents: 200.
    Frequency of Response: 1.
    Average Burden Per Response: 20 minutes.
    Estimated Annual Burden: 67 hours.
    II. The information collection listed below has 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 package 
by calling the SSA Reports Clearance Officer at 410-965-0454, or by 
writing to the addresses listed above.
    1. Youth Transition Process Demonstration Evaluation Data 
Collection--To further the President's New Freedom Initiative goal of 
increasing employment of individuals with disabilities, SSA plans to 
award seven cooperative agreements for the purpose of developing 
service delivery systems to assist youth with disabilities to 
successfully transition from school to work. SSA is funding two 
coordinated contracts to provide (1) technical assistance and (2) an 
evaluation. SSA will work with the Evaluation Contractor to use the 
results to conduct a net outcome evaluation to determine the long-term 
effectiveness of the interventions, impacts and benefits of the 
demonstration. Evaluation data will be used by the projects to improve 
the efficiency of the project's operations; use of staff; linkages 
between the project and the agencies through which comprehensive 
services are arranged; and specific aspects of service delivery to 
better meet the needs of the targeted population. This type of project 
is authorized by sections 1110 and 234 of the Social Security Act. The 
respondents will be youth with disabilities who have enrolled in the 
project.
    Type of Request: New Collection.
    Number of Respondents: 5,000.
    Frequency of Response: 4.
    Average Burden Per Response: 15 minutes.
    Estimated Annual Burden: 5,000 hours.
    2. Certification of Contents of Document(s) or Record(s)--20 CFR 
404.715 ff.--0960-NEW. SSA must secure evidence necessary for 
individuals to establish rights to benefits. Some of the types of 
evidence needed are evidence of age, relationship, citizenship, 
marriage, death, and military service. Form SSA-704 allows SSA 
employees, state record custodians, and other custodians of evidentiary 
documents to record information from documents and records to establish 
these types of evidence. SSA employees use this form but it also is 
used by state record custodians and other custodians of evidentiary 
documents.
    Type of Request: Existing form not previously cleared by OMB.
    Number of Respondents: 4,200.
    Average Burden Per Response: 10 minutes.
    Estimated Annual Burden: 700.
    3. Questionnaire for Children Claiming SSI Payments--0960-0499. The 
information collected on form SSA-3881 is used by SSA to evaluate 
disability in children who apply for SSI payments. The respondents are 
individuals who apply for SSI payments for a disabled child.
    Number of Respondents: 253,000.
    Frequency of Response: 1.
    Average Burden Per Response: 30 minutes.
    Estimated Annual Burden: 126,500 hours.
    4. Certificate of Responsibility for Welfare and Care of Child Not 
in Applicant's Custody--20 CFR 404.330 and 404.339--0960-0019. SSA uses 
the information collected on form SSA-781 to decide if ``in care'' 
requirements are met by non-custodial parent(s), who is filing for 
benefits based on having a child in care. The respondents are non-
custodial wage earners whose entitlement to benefits depends upon 
having an entitled child in care.
    Number of Respondents: 14,000.
    Frequency of Response: 1.
    Average Burden Per Response: 10 minutes.
    Estimated Annual Burden: 2,333 hours.
    5. Social Security Benefits Applications--20 CFR Subpart D, 
404.310-404.311 and 20 CFR Subpart F, 404.601-401.603--0960-0618. One 
of the requirements for obtaining Social Security benefits is the 
filing of an application so that a determination may be made on the 
applicant's eligibility for monthly benefits. In addition to the 
traditional paper application, SSA has developed various options for 
the public to add convenience and operational efficiency to the 
application process. The total estimated number of respondents to all 
application collections formats is 3,843,369 with a cumulative total of 
995,457 burden hours. The respondents are applicants for retirement 
insurance benefits (RIB), disability insurance benefits (DIB), and/or 
spouses' benefits.
    Please note that burden hours for applications taken through the 
Modernized Claims System (MCS) are accounted for in the hardcopy 
collection formats. MCS is an electronic collection method that mirrors 
the hardcopy application formats. Guided by the MCS collection screens, 
an SSA representative interviews the applicant and inputs the 
information directly into SSA's application database. MCS offers the 
representative prompts based on the type of application being filed and 
the circumstances of the applicant. These prompts facilitate a more 
complete initial application, saving both the agency and applicant 
time. MCS also propagates identity and similar information within the 
application, which saves additional time.
    Type of Request: Revision of an OMB-approved information collection 
(ISBA collection only).

Internet Social Security Benefits Application (ISBA)

    ISBA, which is available through SSA's Internet site, is one method 
that an individual can choose to file an application for benefits. 
Individuals can use ISBA to apply for RIB, DIB and spouse's insurance 
benefits based on age. SSA gathers only information relevant to the 
individual applicant's circumstances and will use the information 
collected by ISBA to entitle individuals to RIB, DIB, and/or spouses' 
benefits. The respondents are applicants for RIB, DIB, and/or spouses 
benefits.
    Number of Respondents: 169,000.
    Frequency of Response: 1.
    Average Burden Per Response: 21.4 minutes.
    Estimated Annual Burden: 60,277 hours.

Paper Application Forms

Application for Retirement Insurance Benefits (SSA-1)

    The SSA-1 is used by SSA to determine an individual's entitlement 
to retirement insurance benefits. In order to receive Social Security 
retirement insurance benefits, an individual must file an application 
with SSA. The SSA-1 is one application that the Commissioner of Social 
Security prescribes to meet this requirement. The information that SSA 
collects will be used to determine entitlement to retirement benefits. 
The respondents are individuals who choose to apply for Social Security 
retirement insurance.
    Number of Respondents: 1,460,692.
    Frequency of Response: 1.
    Average Burden Per Response: 10.5 minutes.
    Estimated Annual Burden: 255,621 hours.

[[Page 17728]]

Application for Wife's or Husband's Insurance Benefits (SSA-2)

    SSA uses the information collected on Form SSA-2 to determine if an 
applicant (including a divorced applicant) can be entitled to benefits 
as the spouse of the worker and the amount of the spouse's benefits. 
The respondents are applicants for wife's or husband's benefits, 
including those who are divorced.
    Number of Respondents: 700,000.
    Frequency of Response: 1.
    Average Burden Per Response: 15 minutes.
    Estimated Annual Burden: 175,000 hours.

Application for Disability Insurance Benefits (SSA-16)

    Form SSA-16-F6 obtains the information necessary to determine 
whether the provisions of the Act have been satisfied with respect to 
an applicant for disability benefits, and detects whether the applicant 
has dependents who would qualify for benefits on his or her earnings 
record. The information collected on form SSA-16 helps to determine 
eligibility for Social Security disability benefits. The respondents 
are applicants for Social Security disability benefits.
    Number of Respondents: 1,513,677.
    Frequency of Response: 1.
    Average Burden Per Response: 20 minutes.
    Estimated Annual Burden: 504,559 hours.
    6. Application Statement for Child's Insurance Benefits--20 CFR 
404.350-404.368, 404.603, and 416.350--0960-0010. Title II of the 
Social Security Act provides for payment of monthly benefits to the 
children of an insured retired, disabled, or deceased worker, if 
certain conditions are met. The form SSA-4-BK is used by SSA to collect 
information needed to determine whether the child or children are 
entitled to benefits. The respondents are children of the worker or 
individuals who complete this form on their behalf.
    Type of Request: Extension of an OMB-approved information 
collection.

------------------------------------------------------------------------
                                 Life claims        Death claims
---------------------------------------------------------------------
Number of Respondents........  925,000........  815,000.............
Frequency of Response........  1..............  1...................
Average Burden Per Response..  10.5 minutes...  5.5 minutes.........
Estimated Annual Burden......  161,875 hours..  74,708 hours........
------------------------------------------------------------------------

    7. Modified Benefit Formula Questionnaire-Foreign Pension--0960-
0561. The information collected on form SSA-308 is used by SSA to 
determine exactly how much (if any) of the foreign pension may be used 
to reduce the amount of the Social Security retirement or disability 
benefit under the modified benefit formula. The respondents are 
applicants for Social Security retirement/disability benefits.
    Type of Request: Extension of OMB approved Information collection.
    Number of Responses: 50,000.
    Frequency of Response: 1.
    Average Burden Per Response: 10 minutes.
    Estimated Annual Burden: 8,333 hours.
    8. 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, or lack thereof, to handle his or her own benefits. This 
information also provides SSA with a means of selecting a 
representative payee, if this proves necessary. The respondents are 
beneficiaries' physicians.
    Type of Request: Revision of an OMB-approved information 
collection.

    Please Note: The Federal Register notice published on February 
4, 2004 at 69 FR 5380, cited the ``type of request'' as an 
``Extension of an OMB-approved information collection.'' Since that 
time, SSA decided to revise the form to make minor changes, so we 
are submitting this information collection as a revision.

    Number of Respondents: 120,000.
    Frequency of Response: 1.
    Average Burden Per Response: 10 minutes.
    Estimated Annual Burden: 20,000 hours.
    9. Physical Residual Functional Capacity Assessment and Mental 
Residual Functional Capacity Assessment--20 CFR 404.1545 and 416.945--
0960-0431. The information collected by form SSA-4734 is used in the 
adjudication of disability claims involving physical and/or mental 
impairments. The form provides the State DDS with a standardized data 
collection format to evaluate impairment(s) and to present findings in 
a clear, concise, and consistent manner. The respondents are State DDSs 
administering Title II and Title XVI disability programs.
    Type of Request: Extension of an OMB-approved information 
collection.

    Please Note: The Federal Register notice published on February 
4, 2004 at 69 FR 5380, cited the ``type of request'' as an 
``Extension of an OMB-approved information collection.'' Since that 
time, SSA decided to revise the form so we are submitting this 
information collection as a revision.


------------------------------------------------------------------------
                                   SSA-4734-BK          SSA-4734-SUP
------------------------------------------------------------------------
Number of Respondents.........  1,625,095........  796,770.
Frequency of Response.........  1................  1.
Average Burden Per Response...  20 minutes.......  20 minutes.
Estimated Annual Burden.......  541,698 hours....  265,590 hours.
------------------------------------------------------------------------

    Total Estimated Annual Burden: 807,288 hours.

    Dated: March 30, 2004.
Elizabeth A. Davidson,
Reports Clearance Officer, Social Security Administration.
[FR Doc. 04-7535 Filed 4-2-04; 8:45 am]
BILLING CODE 4191-02-P