[Federal Register Volume 80, Number 101 (Wednesday, May 27, 2015)]
[Notices]
[Pages 30316-30318]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2015-12671]


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SOCIAL SECURITY ADMINISTRATION

[Docket No: SSA-2015-0029]


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 104-13, the 
Paperwork Reduction Act of 1995, effective October 1, 1995. This notice 
includes revisions and extensions 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 ways to minimize burden 
on respondents, including the use of automated collection techniques or 
other forms of information technology. Mail, email, or fax your 
comments and recommendations on the information collection(s) to the 
OMB Desk Officer and SSA Reports Clearance Officer at the following 
addresses or fax numbers.

(OMB), Office of Management and Budget, Attn: Desk Officer for SSA, 
Fax: 202-395-6974, Email address: [email protected].
(SSA), Social Security Administration, OLCA, Attn: Reports Clearance 
Director, 3100 West High Rise, 6401 Security Blvd., Baltimore, MD 
21235, Fax: 410-966-2830, Email address: [email protected].

    Or you may submit your comments online through www.regulations.gov, 
referencing Docket ID Number [SSA-2015-0029].
    I. The information collections below are pending at SSA. SSA will 
submit them 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 July 
27, 2015. Individuals can obtain copies of the collection instruments 
by writing to the above email address.
    1. Statement of Employer--20 CFR 404.801-404.803--0960-0030. When 
workers report they were paid wages but cannot provide proof of those 
earnings, and the wages do not appear in SSA's records of earnings, SSA 
uses Form SSA-7011-F4 to document the alleged wages. Specifically, the 
agency uses the form to resolve discrepancies in the individual's 
Social Security earnings record and to process claims for Social 
Security benefits. We only send Form SSA-7011-F4 to employers if we are 
unable able to locate the earnings information within our own records. 
The respondents are employers who can verify wage allegations made by 
wage earners.
    Type of Request: Revision of an OMB-approved information 
collection.

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                                                                                 Average burden  Estimated total
           Modality of completion                Number of       Frequency of     per response    annual burden
                                                respondents        response        (minutes)         (hours)
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SSA-7011-F4.................................             500                1               20              167
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    2. Function Report Adult-Third Party--20 CFR 404.1512 & 416.912--
0960-0635. Individuals receiving or applying for Social Security 
Disability Insurance (SSDI) or Supplemental Security Income (SSI) 
provide SSA with medical evidence and other proof SSA requires to prove 
their disability. SSA, and Disability Determination Services (DDS) on 
our behalf, collect this information using Form SSA-3380-BK. We use the 
information to document how claimant's disabilities affect their 
ability to function, and to determine eligibility for SSI and SSDI 
claims. The respondents are third parties familiar with the functional 
limitations (or lack thereof) of claimants who apply for SSI and SSDI 
benefits.
    Type of Request: Revision of an OMB approved information 
collection.

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                                                                                 Average burden  Estimated total
           Modality of completion                Number of       Frequency of     per response    annual burden
                                                respondents        response        (minutes)         (hours)
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SSA-3380-BK.................................         780,000                1               61          793,000
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    II. SSA submitted the information collections below to OMB for 
clearance. Your comments regarding the information collections would be 
most useful if OMB and SSA receive them 30 days from the date of this 
publication. To be sure we consider your comments, we must receive them 
no later than June 26, 2015. Individuals can obtain copies of the OMB 
clearance packages by writing to [email protected].
    1. Application for Parent's Insurance Benefits--20 CFR 404.370-
404.374, 20 CFR 404.601-404.603--0960-0012. Section 202(h) of the 
Social Security Act establishes the conditions of eligibility a 
claimant must meet to receive monthly benefits as a parent of a 
deceased worker. SSA uses information from Form SSA-7-F6 to determine 
if the

[[Page 30317]]

claimant meets the eligibility and application criteria. The 
respondents are applicants for, and recipients of, Social Security Old 
Age, Survivors, and Disability Insurance (OASDI).
    Type of Request: Revision of an OMB-approved information 
collection.

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                                                                                 Average burden  Estimated total
           Modality of completion                Number of       Frequency of     per response    annual burden
                                                respondents        response        (minutes)         (hours)
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Modernized Claims System (MCS)..............             153                1               15               38
MCS/Signature Proxy.........................             158                1               14               37
Paper Form..................................               4                1               15                1
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    Total...................................             315   ...............  ...............              76
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    2. Request for Withdrawal of Application--20 CFR 404.640--0960-
0015. Form SSA-521 documents the information SSA needs to process the 
withdrawal of an application for benefits. A paper SSA-521 is our 
preferred instrument for executing a withdrawal request; however, any 
written request for withdrawal signed by the claimant or a proper 
applicant on the claimant's behalf will suffice. Individuals who wish 
to withdraw their applications for benefits complete Form SSA-521, or 
sign the completed form for each request to withdraw. SSA uses the 
information from the SSA-521 to process the request for withdrawal. The 
respondents are applicants for Retirement, Survivors, Disability, and 
Health Insurance benefits.
    Type of Request: Revision of an OMB-approved information 
collection.

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                                                                                 Average burden  Estimated total
           Modality of completion                Number of       Frequency of     per response    annual burden
                                                respondents        response        (minutes)         (hours)
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SSA-521.....................................          39,000                1                5            3,250
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    3. Claimant's Medication--20 CFR 404.1512, 416.912--0960-0289. In 
cases where claimants request a hearing after denial of their 
disability claim for Social Security, SSA uses Form HA-4632 to request 
information from the claimant regarding the medications they use. This 
information helps the administrative law judge overseeing the case to 
fully investigate: (1) The claimant's medical treatment and (2) the 
effects of the medications on the claimant's medical impairments and 
functional capacity. The respondents are applicants (or their 
representatives) for OASDI benefits or SSI payments who request a 
hearing to contest an agency denial of their claim.
    Type of Request: Revision of an OMB-approved information 
collection.

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                                                                                 Average burden  Estimated total
           Modality of completion                Number of       Frequency of     per response    annual burden
                                                respondents        response        (minutes)         (hours)
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HA-4632 (paper).............................          20,000                1               15            5,000
Electronic Records Express..................         180,000                1               15           45,000
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    Total...................................         200,000   ...............  ...............          50,000
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    4. Permanent Residence in the United States Under Color of Law 
(PRUCOL)--20 CFR 416.1615 and 416.1618--0960-0451. As per 20 CFR 
416.1415 and 416.1618 of the Code of Federal Regulations, SSA requires 
claimants or recipients to submit evidence of their alien status when 
they apply for SSI payments, and periodically thereafter as part of the 
eligibility determination process for SSI. When SSA cannot verify 
evidence of alien status through the regular claimant interview 
process, SSA verifies the validity of the evidence of PRUCOL for 
grandfathered nonqualified aliens with the Department of Homeland 
Security (DHS), and determines if the individual qualifies for PRUCOL 
status based on the DHS response. SSA does not maintain any forms or 
applications for respondents to use, rather, the regulations listed in 
20 CFR 416.1615 and 416.1618 specify the information respondents need 
to submit to SSA to show evidence of PRUCOL. Without this information, 
SSA is unable to determine whether the PRUCOL individual is eligible 
for SSI payments. Respondents are qualified and unqualified aliens who 
apply for SSI payments under PRUCOL.
    Type of Request: Extension of an OMB-approved information 
collection.

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                                                                                 Average burden  Estimated total
           Modality of completion                Number of       Frequency of     per response    annual burden
                                                respondents        response        (minutes)         (hours)
----------------------------------------------------------------------------------------------------------------
Personal or Telephone Interview.............           1,049                1                5               87
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[[Page 30318]]

    5. Authorization for the Social Security Administration to Obtain 
Account Records from a Financial Institution and Request for Records 
(Medicare)--0960-0729. The Medicare Prescription Drug, Improvement, and 
Modernization Act of 2003 (MMA) established the Medicare Part D program 
for voluntary prescription drug coverage of premium, deductible, and 
copayment costs for individuals with limited income and resources. The 
MMA mandates that the Government provide subsidies for those 
individuals who qualify for the program, and who meet eligibility 
criteria for help with premium, deductible, or co-payment costs. SSA 
uses the SSA-4640, Authorization for the Social Security Administration 
to Obtain Account Records from a Financial Institution and Request for 
Records (Medicare) to determine if subsidy applicants or recipients 
qualify, or continue to qualify, for the subsidy. SSA uses Form SSA-
4640 to:
    (1) Obtain the individual's consent to verify balances of financial 
institution (FI) accounts; and (2) obtain verification of such balances 
from the FI. Respondents are Medicare Part D program subsidy applicants 
or claimants, and their financial institutions.
    This is a correction notice. SSA published this information 
collection as a revision on March 9, 2015 at 80 FR 12542. Since we are 
not revising the Privacy Act Statement, this is now an extension of an 
OMB-approved information collection.
    Type of Request: Extension of an OMB-approved information 
collection.

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                                                                                 Average burden  Estimated total
           Modality of completion                Number of       Frequency of     per response    annual burden
                                                respondents        response        (minutes)         (hours)
----------------------------------------------------------------------------------------------------------------
Medicare Part D Subsidy Applicants..........           5,000                1                1               83
Financial Institutions......................           5,000                1                4              333
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    Total...................................          10,000   ...............  ...............             416
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    Dated: May 20, 2015.
Faye I. Lipsky,
Reports Clearance Officer, Social Security Administration.
[FR Doc. 2015-12671 Filed 5-26-15; 8:45 am]
 BILLING CODE 4191-02-P