Agency Information Collection Activities: Proposed Request and Comment Request, 15808-15810 [E9-7453]
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15808
Federal Register / Vol. 74, No. 65 / Tuesday, April 7, 2009 / Notices
IV. Solicitation of Comments
Interested persons are invited to
submit written data, views, and
arguments concerning the foregoing,
including whether the proposed rule
change is consistent with the Act.
Comments may be submitted by any of
the following methods:
For the Commission, by the Division of
Trading and Markets, pursuant to delegated
authority.19
Florence E. Harmon,
Deputy Secretary.
[FR Doc. E9–7773 Filed 4–6–09; 8:45 am]
BILLING CODE 8010–01–P
Electronic Comments
• Use the Commission’s Internet
comment form (https://www.sec.gov/
rules/sro.shtml); or
• Send an e-mail to rulecomments@sec.gov. Please include File
Number SR–FINRA–2009–013 on the
subject line.
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
Paper Comments
by the Office of Management and
Budget (OMB) in compliance with
• Send paper comments in triplicate
Public Law (Pub. L.) 104–13, the
to Elizabeth M. Murphy, Secretary,
Paperwork Reduction Act of 1995,
Securities and Exchange Commission,
effective October 1, 1995. This notice
100 F Street, NE., Washington, DC
includes revisions and extensions of
20549–1090.
OMB-approved Information Collections
and a new collection.
All submissions should refer to File
Number SR–FINRA–2009–013. This file
SSA is soliciting comments on the
number should be included on the
accuracy of the agency’s burden
subject line if e-mail is used. To help the estimate; the need for the information;
Commission process and review your
its practical utility; ways to enhance its
comments more efficiently, please use
quality, utility, and clarity; and ways to
only one method. The Commission will minimize the burden on respondents,
post all comments on the Commission’s including the use of automated
Internet Web site (https://www.sec.gov/
collection techniques or other forms of
rules/sro.shtml). Copies of the
information technology. Mail, e-mail, or
submission, all subsequent
fax your comments and
amendments, all written statements
recommendations on the information
with respect to the proposed rule
collection(s) to the OMB Desk Officer
change that are filed with the
and the SSA Reports Clearance Officer
Commission, and all written
to the addresses or fax numbers listed
communications relating to the
below.
proposed rule change between the
(OMB), Office of Management and
Commission and any person, other than
Budget. Attn: Desk Officer for SSA.
those that may be withheld from the
Fax: 202–395–6974. E-mail Address:
public in accordance with the
OIRA_Submission@omb.eop.gov.
provisions of 5 U.S.C. 552, will be
(SSA), Social Security Administration,
available for inspection and copying in
DCBFM, Attn: Reports Clearance
the Commission’s Public Reference
Officer, 1332 Annex Building, 6401
Room, 100 F Street, NE., Washington,
Security Blvd., Baltimore, MD 21235.
DC 20549, on official business days
Fax: 410–965–6400. E-mail Address:
between the hours of 10 a.m. and 3 p.m.
OPLM.RCO@ssa.gov.
All comments received will be posted
without change; the Commission does
I. The information collection below is
not edit personal identifying
pending at SSA. SSA will submit it to
information from submissions. You
OMB within 60 days from the date of
this notice. To be sure we consider your
should submit only information that
you wish to make available publicly. All comments, we must receive them no
later than June 8, 2009. Individuals can
submissions should refer to the File
obtain copies of the collection
Number SR–FINRA–2009–013 and
instrument by calling the SSA Reports
should be submitted on or before April
Clearance Officer at 410–965–3758 or by
28, 2009.
writing to the e-mail address listed
above.
19 17
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18:20 Apr 06, 2009
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CFR 200.30–3(a)(12).
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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 OMBapproved 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 selfemployed 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
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Federal Register / Vol. 74, No. 65 / Tuesday, April 7, 2009 / Notices
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 livingwith spouse. The respondents are
applicants for underpayments owed to
deceased beneficiaries.
Type of Request: Revision of an OMBapproved 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
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17:13 Apr 06, 2009
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relationship to other similar activities of
the respondents. The respondents are
State and local governments, statedesignated 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 OMBapproved 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
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15809
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 OMBapproved information collection.
Type of Request: Revision of an OMBapproved 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.
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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 OMBapproved information collection.
Type of Request: Revision of an OMBapproved 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
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17:13 Apr 06, 2009
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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 OMBapproved 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 OMBapproved 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-orOver Monthly Payments—20 CFR
404.380–404.384—0960–0096
Form SSA–19–F6 collects the
information needed to determine
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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 OMBapproved 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
DEPARTMENT OF STATE
[Public Notice 6568]
Bureau of Educational and Cultural
Affairs (ECA) Request for Grant
Proposals: Youth Leadership
Programs: Sub-Saharan Africa
Announcement Type: New grant.
Funding Opportunity Number: ECA/
PE/C/PY–09–42.
Catalog of Federal Domestic
Assistance Number: 00.000.
Application Deadline: May 21, 2009.
Executive Summary: The Office of
Citizen Exchanges, Youth Programs
Division, of the Bureau of Educational
and Cultural Affairs announces an open
competition for two Youth Leadership
Program grants for countries of SubSaharan Africa, one for 40 participants
from four Anglophone countries
(Nigeria, Tanzania, Kenya and South
Africa), and one for 60 participants from
six Francophone countries (Burkina
Faso, Chad, Cote D’Ivoire, Mali,
Mauritania, and Niger). [Note: Target
countries may be subject to change.]
Public and private non-profit
organizations meeting the provisions
described in Internal Revenue Code
section 26 USC 501(c)(3) may submit
proposals to conduct a minimum of two
U.S.-based three-week exchange projects
for combinations of two Anglophone
countries, or a minimum of three U.S.based three-week exchange projects for
combinations of two Francophone
countries. The project activities will
focus on civic education, leadership,
diversity, and community activism,
which will prepare participants to
conduct follow up activities at home
that serve a community need.
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]]>Agencies
[Federal Register Volume 74, Number 65 (Tuesday, April 7, 2009)]
[Notices]
[Pages 15808-15810]
From the Federal Register Online via the Government Printing 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: 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
[[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
