Agency Information Collection Activities: Proposed Request and Comment Request, 19304-19308 [2017-08403]
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Federal Register / Vol. 82, No. 79 / Wednesday, April 26, 2017 / Notices
including whether the proposed rule
change is consistent with the Act.
Comments may be submitted by any of
the following methods:
Electronic Comments
• Use the Commission’s Internet
comment form (https://www.sec.gov/
rules/sro.shtml); or
• Send an email to rule-comments@
sec.gov. Please include File Number SR–
NYSEMKT–2017–21 on the subject line.
Paper Comments
• Send paper comments in triplicate
to Secretary, Securities and Exchange
Commission, 100 F Street NE.,
Washington, DC 20549–1090.
All submissions should refer to File
Number SR–NYSEMKT–2017–21. This
file number should be included on the
subject line if email is used. To help the
Commission process and review your
comments more efficiently, please use
only one method. The Commission will
post all comments on the Commission’s
Internet Web site (https://www.sec.gov/
rules/sro.shtml). Copies of the
submission, all subsequent
amendments, all written statements
with respect to the proposed rule
change that are filed with the
Commission, and all written
communications relating to the
proposed rule change between the
Commission and any person, other than
those that may be withheld from the
public in accordance with the
provisions of 5 U.S.C. 552, will be
available for Web site viewing and
printing in the Commission’s Public
Reference Room, 100 F Street NE.,
Washington, DC 20549, on official
business days between the hours of
10:00 a.m. and 3:00 p.m. Copies of the
filing also will be available for
inspection and copying at the principal
office of the Exchange. All comments
received will be posted without change;
the Commission does not edit personal
identifying information from
submissions. You should submit only
information that you wish to make
available publicly. All submissions
should refer to File Number SR–
NYSEMKT–2017–21, and should be
submitted on or before May 17, 2017.
For the Commission, by the Division of
Trading and Markets, pursuant to delegated
authority.22
Eduardo A. Aleman,
Assistant Secretary.
[FR Doc. 2017–08388 Filed 4–25–17; 8:45 am]
BILLING CODE 8011–01–P
SOCIAL SECURITY ADMINISTRATION
[Docket No: SSA–2017–0020]
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 on extension 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
Number of
respondents
Modality of completion
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:
OIRA_Submission@omb.eop.gov.
(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:
OR.Reports.Clearance@ssa.gov
Or you may submit your comments
online through www.regulations.gov,
referencing Docket ID Number [SSA–
2017–0020].
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 June 26,
2017. Individuals can obtain copies of
the collection instruments by writing to
the above email address.
1. Application for Benefits under a
U.S. International Social Security
Agreement—20 CFR 404.1925—0960–
0448. Section 233(a) of the Social
Security Act (Act) authorizes the
President to broker international Social
Security agreements (Totalization
Agreements) between the United States
and foreign countries. SSA collects
information using Form SSA–2490–BK
to determine entitlement to Social
Security benefits from the United States,
or from a country that enters into a
Totalization Agreement with the United
States. The respondents are individuals
applying for Old Age Survivors and
Disability Insurance (OASDI) benefits
from the United States or from a
Totalization Agreement country.
Type of Request: Revision of an OMBapproved information collection.
Average
burden per
response
(minutes)
Frequency
of response
Estimated
total annual
burden
(hours)
15,030
2,120
1
1
30
30
7,515
1,060
Totals ........................................................................................................
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SSA–2490–BK (MCS) .....................................................................................
SSA–2490–BK (paper) ....................................................................................
17,150
........................
........................
8,575
2. Medicare Part D Subsidies
Regulations—20 CFR 418.3625(c),
418.3645, 418.3665(a), and 418.3670—
0960–0702. The Medicare Prescription
Drug Improvement and Modernization
Act (MMA) of 2003 established the
Medicare Part D program for voluntary
prescription drug coverage of premium,
22 17
deductible, and co-payment costs for
certain low-income individuals. The
MMA also mandated the provision of
subsidies for those individuals who
qualify for the program and who meet
eligibility criteria for help with
premium, deductible, or co-payment
costs. This law requires SSA to make
eligibility determinations, and to
provide a process for appealing SSA’s
determinations. Regulation sections
418.3625(c), 418.3645, 418.3665(a), and
418.3670 contain public reporting
requirements pertaining to
administrative review hearings.
Respondents are applicants for the
CFR 200.30–3(a)(12).
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Medicare Part D subsidies who request
an administrative review hearing.
Type of Request: Revision of an OMBapproved information collection.
Number of
respondents
Modality of completion
Average
burden per
response
(minutes)
Frequency
of response
Estimated
total annual
burden
(hours)
418.3625(c) ......................................................................................................
418.3645 ..........................................................................................................
418.3665(a) ......................................................................................................
418.3670 * ........................................................................................................
140
10
275
0
1
1
1
1
5
10
5
10
12
2
23
0
Total ..........................................................................................................
425
........................
........................
37
* Regulation section 418.3670 could be used at any time; however, we currently have no data showing usage over the past three years.
II. SSA submitted the information
collections below to OMB for clearance.
Your comments regarding these
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 May
26, 2017. Individuals can obtain copies
of the OMB clearance packages by
writing to OR.Reports.Clearance@
ssa.gov.
1. Government Pension
Questionnaire—20 CFR 404.408a—
0960–0160. The basic Social Security
benefits application (OMB No. 0960–
0618) contains a lead question asking if
the applicants are qualified (or will
qualify) to receive a government
pension. If the respondent is qualified,
or will qualify, to receive a government
pension, the applicant completes Form
SSA–3885 either on paper or through a
personal interview with an SSA claims
representative. If the applicants are not
entitled to receive a government
pension at the time they apply for Social
Security benefits, SSA requires them to
provide the government pension
information as beneficiaries when they
become eligible to receive their
pensions. Regardless of the timing, at
some point the applicants or
beneficiaries must complete and sign
Form SSA–3885 to report information
about their government pensions before
the pensions begin. SSA uses the
information to: (1) Determine whether
the Government Pension Offset
provision applies; (2) identify
exceptions as stated in 20 CFR 404.408a;
and (3) determine the benefit reduction
amount and effective date. If the
applicants and beneficiaries do not
respond using this questionnaire, SSA
offsets their entire benefit amount. The
respondents are applicants or recipients
of spousal benefits who are eligible for
or already receiving a Government
pension.
Type of Request: Revision of an OMBapproved information collection.
Modality of completion
Number of
respondents
Frequency
of response
Average
burden per
response
(minutes)
Estimated
total annual
burden
(hours)
SSA–3885 ........................................................................................................
76,000
1
13
16,467
2. Request for Review of Hearing
Decision/Order—20 CFR 404.967–
404.981, 416.1467–416.1481—0960–
0277. Claimants have a statutory right
under the Act and current regulations to
request review of an administrative law
judge’s (ALJ) hearing decision or
dismissal of a hearing request on Title
II and Title XVI claims. Claimants may
request Appeals Council review by
filing a written request using Form HA–
520. SSA uses the information to
establish the claimant filed the request
for review within the prescribed time
and to ensure the claimant completed
the requisite steps permitting the
Appeals Council review. The Appeals
Council uses the information to: (1)
Document the claimant’s reason(s) for
disagreeing with the ALJ’s decision or
dismissal; (2) determine whether the
claimant has additional evidence to
submit; and (3) determine whether the
claimant has a representative or wants
to appoint one. The respondents are
claimants requesting review of an ALJ’s
decision or dismissal of hearing.
Type of Request: Revision of an OMBapproved information collection.
Number of
respondents
Frequency
of response
Average
burden per
response
(minutes)
Estimated total
annual
burden
(hours)
HA–520 ............................................................................................................
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Modality of completion
175,000
1
10
29,167
3. Modified Benefit Formula
Questionnaire—0960–0395. SSA
collects information on Form SSA–150
to determine which formula to use in
computing the Social Security benefit
for someone who receives a pension
from employment not covered by Social
Security. The Windfall Elimination
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Provision (WEP) requires use of a
benefit formula replacing a smaller
percentage of a worker’s pre-retirement
earnings. However, the resulting amount
cannot show a difference in the benefit
computed using the modified and
regular formulas greater than one-half
the amount of the pension received in
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the first month an individual is entitled
to both the pension and the Social
Security benefit. The SSA–150 collects
the information needed to make all the
necessary benefit computations. SSA
requires respondents to furnish the
information on Form SSA–150 so we
can calculate their benefits using the
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data they supply. SSA calculates the
benefits of applicants who do not
respond to this questionnaire using the
full WEP reduction. SSA employees
collect this information once from the
applicant at the time they file their
claim. The respondents are applicants
for old age and disability benefits.
Type of Request: Revision of an OMBapproved information collection.
Modality of completion
Number of
respondents
Frequency
of response
Average
burden per
response
(minutes)
Estimated
total annual
burden
(hours)
SSA–150 ..........................................................................................................
90,000
1
8
12,000
4. Modified Benefit Formula
Questionnaire-Employer—20 CFR 401 &
402—0960–0477. Sections 215(a)(7) and
215(d)(3) of the Act require SSA to use
a modified benefit formula to compute
Social Security retirement or disability
benefits for persons first eligible (after
1985) for both a Social Security benefit
and a pension or annuity, based on
employment not covered by Social
Security. This method is the WEP. SSA
makes a determination regarding
whether the WEP is applicable and
when to apply it to a person’s benefit.
SSA uses Form SSA–58 to verify the
claimant’s allegations on Form SSA–150
(OMB #0906–0395, Modified Benefits
Formula Questionnaire). SSA also uses
Form SSA–58 to determine if the
modified benefit formula is applicable
and when to apply it to a person’s
benefits. SSA sends Form SSA–58 to an
employer for pension related
information, if the claimant is unable to
provide it. The respondents are
employers of people who are eligible
after 1985 for both Social Security
benefits and a pension based on work
not covered by SSA.
Type of Request: Revision of an OMBapproved information collection.
Modality of completion
Number of
respondents
Frequency
of response
Average
burden per
response
(minutes)
Estimated
total annual
burden
(hours)
SSA–58 ............................................................................................................
30,000
1
20
10,000
5. Questionnaire for Children
Claiming Supplemental Security Income
(SSI) Benefits—0960–0499. Section
1631(d)(2) of the Act allows SSA to
determine the eligibility of an
applicant’s claim for Supplemental
Security Income (SSI) payments. Parents
or legal guardians seeking to obtain or
retain SSI eligibility for their children
use Form SSA–3881–BK to provide SSA
with the addresses of non-medical
sources such as schools, counselors,
agencies, organizations, or therapists
who would have information about a
child’s functioning. SSA uses this
information to help determine a child’s
Number of
respondents
Modality of completion
claim or continuing eligibility for SSI.
The respondents are applicants who
appeal SSI childhood disability
decisions or recipients undergoing a
continuing disability review.
Type of Request: Revision of an OMBapproved information collection.
Average
burden per
response
(minutes)
Frequency
of response
Estimated
total annual
burden
(hours)
SSA–3881–BK (Paper Version) ......................................................................
SSA–3881–BK (Electronic Disability Collect System) .....................................
84,500
45,500
1
1
30
30
42,250
22,750
Totals ........................................................................................................
130,000
........................
........................
65,000
6. Work History Report—20 CFR
404.1515, 404.1560, 404.1565, 416.960
and 416.3965—0960–0578. Under
certain circumstances, SSA asks
individuals applying for disability about
work they have performed in the past.
Applicants use Form SSA–3369, Work
History Report, to provide detailed
information about jobs held prior to
becoming unable to work. State
Disability Determination Services
evaluate the information, together with
Number of
respondents
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Modality of completion
medical evidence, to determine
eligibility for disability payments.
Respondents are disability applicants
and third parties assisting applicants.
Type of Request: Revision of an OMBapproved information collection.
Average
burden per
response
(minutes)
Frequency
of response
Estimated
total annual
burden
(hours)
SSA–3369 (Paper Version) .............................................................................
SSA–3369 (Electronic Disability Collect System) ............................................
1,553,900
38,049
1
1
60
60
1,553,900
38,049
Totals ........................................................................................................
1,591,949
........................
........................
1,591,949
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7. Authorization To Obtain Earnings
Data From the Social Security
Administration—0960–0602. On
occasion, public and private
organizations and agencies need to
obtain detailed earnings information
about specific Social Security number
(SSN) holding wage earners for business
purposes (e.g., pension funds, State
Number of
respondents
Modality of completion
SSA–581 ..........................................................................................................
8. Appeal of Determination for Help
With Medicare Prescription Drug Plan
Costs—0960–0695. Public Law 108–173,
the MMA of 2003 established the
Medicare Part D program for voluntary
prescription drug coverage for certain
low-income individuals. The MMA
stipulates the provision of subsidies for
individuals who are eligible for the
wage earner authorized SSA to release
this information to the requesting party;
and (4) produce the Itemized Statement
of Earnings (SSA–1826). The
respondents are private businesses, state
or local agencies, and other federal
agencies.
Type of Request: Revision of an OMBapproved information collection.
agencies, etc.). Respondents use Form
SSA–581 to identify the SSN holder
whose information they are requesting,
and provide authorization from the SSN
holder, when applicable. SSA uses the
information provided on Form SSA–581
to: (1) Identify the wage earner; (2)
establish the period of earnings
information requested; (3) verify the
24,000
1
Estimated
total annual
burden
(hours)
2
800
Medicare Part D subsidy. The
respondents are Medicare beneficiaries,
or proper applicants acting on behalf of
a Medicare beneficiary, who do not
agree with the outcome of an SSA
subsidy eligibility determination, and
are filing an appeal.
Type of Request: Revision of an OMBapproved information collection.
program and who meet eligibility
criteria for help with premium,
deductible, and co-payment costs. SSA
uses Form SSA–1021, Appeal of
Determination for Help With Medicare
Prescription Drug Plan Costs, to obtain
information from individuals who
appeal SSA’s decisions regarding
eligibility or continuing eligibility for a
Number of
respondents
Modality of completion
Average
burden per
response
(minutes)
Frequency
of response
Average
burden per
response
(minutes)
Frequency
of response
Estimated
total
annual
burden
(hours)
SSA–1021 (Paper Version) .............................................................................
SSA–1021 (Internet Version; Medicare Application Processing System) .......
3,283
11,037
1
1
10
10
547
1,840
Totals ........................................................................................................
14,320
........................
........................
2,387
9. Sheltered Workshop Wage
Reporting—0960–0771. Sheltered
workshops are non-profit organizations
or institutions that implement a
recognized program of rehabilitation for
handicapped workers, or provide such
workers with remunerative employment
or other occupational rehabilitating
activity of an educational or therapeutic
nature. Sheltered workshops perform a
service for their clients by reporting
monthly wages directly to SSA. SSA
uses the information these workshops
provide to verify and post monthly
wages to the SSI recipient’s record. Most
workshops report monthly wage totals
to their local SSA office so we can
adjust the client’s SSI payment amount
in a timely manner and prevent
overpayments. Sheltered workshops are
motivated to report wages voluntarily as
a service to their clients. Respondents
are sheltered workshops that report
monthly wages for services performed
in the workshop.
Type of Request: Extension of an
OMB-approved information collection.
Number of
respondents
Frequency
of response
Average
burden per
response
(minutes)
Estimated
total annual
burden
(hours)
Sheltered Workshop Wage Reporting .............................................................
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Modality of completion
800
12
15
2,400
10. Medicare Income-Related Monthly
Adjustment Amount—Life-Changing
Event Form—0960–0784. Federally
mandated reductions in the Federal
Medicare Part B and prescription drug
coverage subsidies result in selected
Medicare recipients paying higher
premiums with income above a specific
threshold. The amount of the premium
subsidy reduction is an income-related
monthly adjustment amount (IRMAA).
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The Internal Revenue Service (IRS)
transmits income tax return data to SSA
for SSA to determine the IRMAA. SSA
uses the Form SSA–44 to determine if
a recipient qualifies for a reduction in
the IRMAA. If affected Medicare
recipients believe SSA should use more
recent tax data because of a lifechanging event that significantly
reduces their income, they can report
these changes to SSA and ask for a new
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initial determination of their IRMAA.
The respondents are Medicare Part B
and prescription drug coverage
recipients and enrollees with modified
adjusted gross income over a highincome threshold who experience one
of eight significant life-changing events.
Type of Request: Revision of an OMBapproved information collection.
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Number of
respondents
Modality of completion
Average
burden per
response
(minutes)
Frequency
of response
Estimated
total annual
burden
(hours)
SSA–44 (Personal Interview in SSA field office) .............................................
SSA–44 (Paper Version) .................................................................................
140,378
60,162
1
1
30
45
70,189
45,122
Totals ........................................................................................................
200,540
........................
........................
115,311
Dated: April 21, 2017.
Naomi R. Sipple,
Reports Clearance Officer, Social Security
Administration.
DEPARTMENT OF STATE
[Public Notice: 9966]
30-Day Notice of Proposed Information
Collection: Affidavit of Relationship
(AOR) for Minors Who Are Nationals of
El Salvador, Guatemala, or Honduras
[FR Doc. 2017–08403 Filed 4–25–17; 8:45 am]
BILLING CODE 4191–02–P
DEPARTMENT OF STATE
Notice of request for public
comment and submission to OMB of
proposed collection of information.
[Public Notice: 9977]
SUMMARY:
ACTION:
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Designation of Mubarak Mohammed A
Alotaibi, aka Abu Ghayth, aka Waqqas
al-Jazrawi, as a Specially Designated
Global Terrorist
Acting under the authority of and in
accordance with section 1(b) of
Executive Order 13224 of September 23,
2001, as amended by Executive Order
13268 of July 2, 2002, and Executive
Order 13284 of January 23, 2003, I
hereby determine that the person known
as Mubarak Mohammed A Alotaibi, aka
Abu Ghayth, aka Waqqas al-Jazrawi,
poses a significant risk of committing
acts of terrorism that threaten the
security of U.S. nationals or the national
security, foreign policy, or economy of
the United States.
Consistent with the determination in
section 10 of Executive Order 13224 that
prior notice to persons determined to be
subject to the Order who might have a
constitutional presence in the United
States would render ineffectual the
blocking and other measures authorized
in the Order because of the ability to
transfer funds instantaneously, I
determine that no prior notice needs to
be provided to any person subject to this
determination who might have a
constitutional presence in the United
States, because to do so would render
ineffectual the measures authorized in
the Order.
This notice shall be published in the
Federal Register.
SUPPLEMENTARY INFORMATION:
Dated: March 23, 2017.
Rex W. Tillerson,
Secretary of State.
[FR Doc. 2017–08431 Filed 4–25–17; 8:45 am]
BILLING CODE 4710–AD–P
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The Department of State has
submitted the information collection
described below to the Office of
Management and Budget (OMB) for
approval. In accordance with the
Paperwork Reduction Act of 1995 we
are requesting comments on this
collection from all interested
individuals and organizations. The
purpose of this Notice is to allow 30
days for public comment.
DATES: Submit comments directly to the
Office of Management and Budget
(OMB) up to May 26, 2017.
ADDRESSES: Direct comments to the
Department of State Desk Officer in the
Office of Information and Regulatory
Affairs at the Office of Management and
Budget (OMB). You may submit
comments by the following methods:
• Email:
oira_submission@omb.eop.gov. You
must include the DS form number,
information collection title, and the
OMB control number in the subject line
of your message.
• Fax: 202–395–5806. Attention: Desk
Officer for Department of State.
FOR FURTHER INFORMATION CONTACT:
Direct requests for additional
information regarding the collection
listed in this notice, including requests
for copies of the proposed collection
instrument and supporting documents,
to Monica Greco, PRM/Office of
Admissions, 2025 E Street NW.,
Washington DC 20522, who may be
reached on 202–453–9251 or at
GrecoMC@state.gov.
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• Title of Information Collection:
Affidavit of Relationship (AOR) for
Minors Who Are Nationals Of El
Salvador, Guatemala, and Honduras.
• OMB Control Number: 1405–0217.
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• Type of Request: Revision of a
Currently Approved Collection.
• Originating Office: PRM/A.
• Form Number: DS–7699.
• Respondents: Lawfully present
parents in the U.S. with children in El
Salvador, Guatemala, and Honduras.
• Estimated Number of Respondents:
5,000.
• Estimated Number of Responses:
5,000.
• Average Time Per Response: 120
minutes per response.
• Total Estimated Burden Time:
10,000 hours.
• Frequency: Once per respondent.
• Obligation to Respond: Required to
Obtain or Retain a Benefit.
We are soliciting public comments to
permit the Department to:
• Evaluate whether the proposed
information collection is necessary for
the proper functions of the Department.
• Evaluate the accuracy of our
estimate of the time and cost burden for
this proposed collection, including the
validity of the methodology and
assumptions used.
• Enhance the quality, utility, and
clarity of the information to be
collected.
• Minimize the reporting burden on
those who are to respond, including the
use of automated collection techniques
or other forms of information
technology.
Please note that comments submitted
in response to this Notice are public
record. Before including any detailed
personal information, you should be
aware that your comments as submitted,
including your personal information,
will be available for public review.
Abstract of Proposed Collection
The Department of State Bureau of
Population, Refugees, and Migration
(PRM) is responsible for coordinating
and managing the U.S. Refugee
Admissions Program (USRAP). PRM
coordinates within the Department of
State, as well as with the Department of
Homeland Security’s U.S. Citizenship
and Immigration Services (DHS/USCIS),
in carrying out this responsibility. A
critical part of the State Department’s
responsibility is determining which
individuals, from among millions of
refugees worldwide, will have access to
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[Federal Register Volume 82, Number 79 (Wednesday, April 26, 2017)]
[Notices]
[Pages 19304-19308]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2017-08403]
=======================================================================
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SOCIAL SECURITY ADMINISTRATION
[Docket No: SSA-2017-0020]
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 on extension 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: OIRA_Submission@omb.eop.gov.
(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: OR.Reports.Clearance@ssa.gov
Or you may submit your comments online through www.regulations.gov,
referencing Docket ID Number [SSA-2017-0020].
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 June
26, 2017. Individuals can obtain copies of the collection instruments
by writing to the above email address.
1. Application for Benefits under a U.S. International Social
Security Agreement--20 CFR 404.1925--0960-0448. Section 233(a) of the
Social Security Act (Act) authorizes the President to broker
international Social Security agreements (Totalization Agreements)
between the United States and foreign countries. SSA collects
information using Form SSA-2490-BK to determine entitlement to Social
Security benefits from the United States, or from a country that enters
into a Totalization Agreement with the United States. The respondents
are individuals applying for Old Age Survivors and Disability Insurance
(OASDI) benefits from the United States or from a Totalization
Agreement country.
Type of Request: Revision of an OMB-approved information
collection.
----------------------------------------------------------------------------------------------------------------
Average Estimated
Number of Frequency of burden per total annual
Modality of completion respondents response response burden
(minutes) (hours)
----------------------------------------------------------------------------------------------------------------
SSA-2490-BK (MCS)............................... 15,030 1 30 7,515
SSA-2490-BK (paper)............................. 2,120 1 30 1,060
---------------------------------------------------------------
Totals...................................... 17,150 .............. .............. 8,575
----------------------------------------------------------------------------------------------------------------
2. Medicare Part D Subsidies Regulations--20 CFR 418.3625(c),
418.3645, 418.3665(a), and 418.3670--0960-0702. The Medicare
Prescription Drug Improvement and Modernization Act (MMA) of 2003
established the Medicare Part D program for voluntary prescription drug
coverage of premium, deductible, and co-payment costs for certain low-
income individuals. The MMA also mandated the provision of subsidies
for those individuals who qualify for the program and who meet
eligibility criteria for help with premium, deductible, or co-payment
costs. This law requires SSA to make eligibility determinations, and to
provide a process for appealing SSA's determinations. Regulation
sections 418.3625(c), 418.3645, 418.3665(a), and 418.3670 contain
public reporting requirements pertaining to administrative review
hearings. Respondents are applicants for the
[[Page 19305]]
Medicare Part D subsidies who request an administrative review hearing.
Type of Request: Revision of an OMB-approved information
collection.
----------------------------------------------------------------------------------------------------------------
Average Estimated
Number of Frequency of burden per total annual
Modality of completion respondents response response burden
(minutes) (hours)
----------------------------------------------------------------------------------------------------------------
418.3625(c)..................................... 140 1 5 12
418.3645........................................ 10 1 10 2
418.3665(a)..................................... 275 1 5 23
418.3670 *...................................... 0 1 10 0
---------------------------------------------------------------
Total....................................... 425 .............. .............. 37
----------------------------------------------------------------------------------------------------------------
* Regulation section 418.3670 could be used at any time; however, we currently have no data showing usage over
the past three years.
II. SSA submitted the information collections below to OMB for
clearance. Your comments regarding these 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 May 26, 2017. Individuals can obtain copies of the
OMB clearance packages by writing to OR.Reports.Clearance@ssa.gov.
1. Government Pension Questionnaire--20 CFR 404.408a--0960-0160.
The basic Social Security benefits application (OMB No. 0960-0618)
contains a lead question asking if the applicants are qualified (or
will qualify) to receive a government pension. If the respondent is
qualified, or will qualify, to receive a government pension, the
applicant completes Form SSA-3885 either on paper or through a personal
interview with an SSA claims representative. If the applicants are not
entitled to receive a government pension at the time they apply for
Social Security benefits, SSA requires them to provide the government
pension information as beneficiaries when they become eligible to
receive their pensions. Regardless of the timing, at some point the
applicants or beneficiaries must complete and sign Form SSA-3885 to
report information about their government pensions before the pensions
begin. SSA uses the information to: (1) Determine whether the
Government Pension Offset provision applies; (2) identify exceptions as
stated in 20 CFR 404.408a; and (3) determine the benefit reduction
amount and effective date. If the applicants and beneficiaries do not
respond using this questionnaire, SSA offsets their entire benefit
amount. The respondents are applicants or recipients of spousal
benefits who are eligible for or already receiving a Government
pension.
Type of Request: Revision of an OMB-approved information
collection.
----------------------------------------------------------------------------------------------------------------
Average burden Estimated total
Modality of completion Number of Frequency of per response annual burden
respondents response (minutes) (hours)
----------------------------------------------------------------------------------------------------------------
SSA-3885.................................... 76,000 1 13 16,467
----------------------------------------------------------------------------------------------------------------
2. Request for Review of Hearing Decision/Order--20 CFR 404.967-
404.981, 416.1467-416.1481--0960-0277. Claimants have a statutory right
under the Act and current regulations to request review of an
administrative law judge's (ALJ) hearing decision or dismissal of a
hearing request on Title II and Title XVI claims. Claimants may request
Appeals Council review by filing a written request using Form HA-520.
SSA uses the information to establish the claimant filed the request
for review within the prescribed time and to ensure the claimant
completed the requisite steps permitting the Appeals Council review.
The Appeals Council uses the information to: (1) Document the
claimant's reason(s) for disagreeing with the ALJ's decision or
dismissal; (2) determine whether the claimant has additional evidence
to submit; and (3) determine whether the claimant has a representative
or wants to appoint one. The respondents are claimants requesting
review of an ALJ's decision or dismissal of hearing.
Type of Request: Revision of an OMB-approved information
collection.
----------------------------------------------------------------------------------------------------------------
Average burden Estimated total
Modality of completion Number of Frequency of per response annual burden
respondents response (minutes) (hours)
----------------------------------------------------------------------------------------------------------------
HA-520...................................... 175,000 1 10 29,167
----------------------------------------------------------------------------------------------------------------
3. Modified Benefit Formula Questionnaire--0960-0395. SSA collects
information on Form SSA-150 to determine which formula to use in
computing the Social Security benefit for someone who receives a
pension from employment not covered by Social Security. The Windfall
Elimination Provision (WEP) requires use of a benefit formula replacing
a smaller percentage of a worker's pre-retirement earnings. However,
the resulting amount cannot show a difference in the benefit computed
using the modified and regular formulas greater than one-half the
amount of the pension received in the first month an individual is
entitled to both the pension and the Social Security benefit. The SSA-
150 collects the information needed to make all the necessary benefit
computations. SSA requires respondents to furnish the information on
Form SSA-150 so we can calculate their benefits using the
[[Page 19306]]
data they supply. SSA calculates the benefits of applicants who do not
respond to this questionnaire using the full WEP reduction. SSA
employees collect this information once from the applicant at the time
they file their claim. The respondents are applicants for old age and
disability benefits.
Type of Request: Revision of an OMB-approved information
collection.
----------------------------------------------------------------------------------------------------------------
Average burden Estimated total
Modality of completion Number of Frequency of per response annual burden
respondents response (minutes) (hours)
----------------------------------------------------------------------------------------------------------------
SSA-150..................................... 90,000 1 8 12,000
----------------------------------------------------------------------------------------------------------------
4. Modified Benefit Formula Questionnaire-Employer--20 CFR 401 &
402--0960-0477. Sections 215(a)(7) and 215(d)(3) of the Act require SSA
to use a modified benefit formula to compute Social Security retirement
or disability benefits for persons first eligible (after 1985) for both
a Social Security benefit and a pension or annuity, based on employment
not covered by Social Security. This method is the WEP. SSA makes a
determination regarding whether the WEP is applicable and when to apply
it to a person's benefit. SSA uses Form SSA-58 to verify the claimant's
allegations on Form SSA-150 (OMB #0906-0395, Modified Benefits Formula
Questionnaire). SSA also uses Form SSA-58 to determine if the modified
benefit formula is applicable and when to apply it to a person's
benefits. SSA sends Form SSA-58 to an employer for pension related
information, if the claimant is unable to provide it. The respondents
are employers of people who are eligible after 1985 for both Social
Security benefits and a pension based on work not covered by SSA.
Type of Request: Revision of an OMB-approved information
collection.
----------------------------------------------------------------------------------------------------------------
Average burden Estimated total
Modality of completion Number of Frequency of per response annual burden
respondents response (minutes) (hours)
----------------------------------------------------------------------------------------------------------------
SSA-58...................................... 30,000 1 20 10,000
----------------------------------------------------------------------------------------------------------------
5. Questionnaire for Children Claiming Supplemental Security Income
(SSI) Benefits--0960-0499. Section 1631(d)(2) of the Act allows SSA to
determine the eligibility of an applicant's claim for Supplemental
Security Income (SSI) payments. Parents or legal guardians seeking to
obtain or retain SSI eligibility for their children use Form SSA-3881-
BK to provide SSA with the addresses of non-medical sources such as
schools, counselors, agencies, organizations, or therapists who would
have information about a child's functioning. SSA uses this information
to help determine a child's claim or continuing eligibility for SSI.
The respondents are applicants who appeal SSI childhood disability
decisions or recipients undergoing a continuing disability review.
Type of Request: Revision of an OMB-approved information
collection.
----------------------------------------------------------------------------------------------------------------
Average Estimated
Number of Frequency of burden per total annual
Modality of completion respondents response response burden
(minutes) (hours)
----------------------------------------------------------------------------------------------------------------
SSA-3881-BK (Paper Version)..................... 84,500 1 30 42,250
SSA-3881-BK (Electronic Disability Collect 45,500 1 30 22,750
System)........................................
---------------------------------------------------------------
Totals...................................... 130,000 .............. .............. 65,000
----------------------------------------------------------------------------------------------------------------
6. Work History Report--20 CFR 404.1515, 404.1560, 404.1565,
416.960 and 416.3965--0960-0578. Under certain circumstances, SSA asks
individuals applying for disability about work they have performed in
the past. Applicants use Form SSA-3369, Work History Report, to provide
detailed information about jobs held prior to becoming unable to work.
State Disability Determination Services evaluate the information,
together with medical evidence, to determine eligibility for disability
payments. Respondents are disability applicants and third parties
assisting applicants.
Type of Request: Revision of an OMB-approved information
collection.
----------------------------------------------------------------------------------------------------------------
Average Estimated
Number of Frequency of burden per total annual
Modality of completion respondents response response burden
(minutes) (hours)
----------------------------------------------------------------------------------------------------------------
SSA-3369 (Paper Version)........................ 1,553,900 1 60 1,553,900
SSA-3369 (Electronic Disability Collect System). 38,049 1 60 38,049
---------------------------------------------------------------
Totals...................................... 1,591,949 .............. .............. 1,591,949
----------------------------------------------------------------------------------------------------------------
[[Page 19307]]
7. Authorization To Obtain Earnings Data From the Social Security
Administration--0960-0602. On occasion, public and private
organizations and agencies need to obtain detailed earnings information
about specific Social Security number (SSN) holding wage earners for
business purposes (e.g., pension funds, State agencies, etc.).
Respondents use Form SSA-581 to identify the SSN holder whose
information they are requesting, and provide authorization from the SSN
holder, when applicable. SSA uses the information provided on Form SSA-
581 to: (1) Identify the wage earner; (2) establish the period of
earnings information requested; (3) verify the wage earner authorized
SSA to release this information to the requesting party; and (4)
produce the Itemized Statement of Earnings (SSA-1826). The respondents
are private businesses, state or local agencies, and other federal
agencies.
Type of Request: Revision of an OMB-approved information
collection.
----------------------------------------------------------------------------------------------------------------
Average Estimated
Number of Frequency of burden per total annual
Modality of completion respondents response response burden
(minutes) (hours)
----------------------------------------------------------------------------------------------------------------
SSA-581......................................... 24,000 1 2 800
----------------------------------------------------------------------------------------------------------------
8. Appeal of Determination for Help With Medicare Prescription Drug
Plan Costs--0960-0695. Public Law 108-173, the MMA of 2003 established
the Medicare Part D program for voluntary prescription drug coverage
for certain low-income individuals. The MMA stipulates the provision of
subsidies for individuals who are eligible for the program and who meet
eligibility criteria for help with premium, deductible, and co-payment
costs. SSA uses Form SSA-1021, Appeal of Determination for Help With
Medicare Prescription Drug Plan Costs, to obtain information from
individuals who appeal SSA's decisions regarding eligibility or
continuing eligibility for a Medicare Part D subsidy. The respondents
are Medicare beneficiaries, or proper applicants acting on behalf of a
Medicare beneficiary, who do not agree with the outcome of an SSA
subsidy eligibility determination, and are filing an appeal.
Type of Request: Revision of an OMB-approved information
collection.
----------------------------------------------------------------------------------------------------------------
Average Estimated
Number of Frequency of burden per total annual
Modality of completion respondents response response burden
(minutes) (hours)
----------------------------------------------------------------------------------------------------------------
SSA-1021 (Paper Version)........................ 3,283 1 10 547
SSA-1021 (Internet Version; Medicare Application 11,037 1 10 1,840
Processing System).............................
---------------------------------------------------------------
Totals...................................... 14,320 .............. .............. 2,387
----------------------------------------------------------------------------------------------------------------
9. Sheltered Workshop Wage Reporting--0960-0771. Sheltered
workshops are non-profit organizations or institutions that implement a
recognized program of rehabilitation for handicapped workers, or
provide such workers with remunerative employment or other occupational
rehabilitating activity of an educational or therapeutic nature.
Sheltered workshops perform a service for their clients by reporting
monthly wages directly to SSA. SSA uses the information these workshops
provide to verify and post monthly wages to the SSI recipient's record.
Most workshops report monthly wage totals to their local SSA office so
we can adjust the client's SSI payment amount in a timely manner and
prevent overpayments. Sheltered workshops are motivated to report wages
voluntarily as a service to their clients. Respondents are sheltered
workshops that report monthly wages for services performed in the
workshop.
Type of Request: Extension of an OMB-approved information
collection.
----------------------------------------------------------------------------------------------------------------
Average burden Estimated total
Modality of completion Number of Frequency of per response annual burden
respondents response (minutes) (hours)
----------------------------------------------------------------------------------------------------------------
Sheltered Workshop Wage Reporting........... 800 12 15 2,400
----------------------------------------------------------------------------------------------------------------
10. Medicare Income-Related Monthly Adjustment Amount--Life-
Changing Event Form--0960-0784. Federally mandated reductions in the
Federal Medicare Part B and prescription drug coverage subsidies result
in selected Medicare recipients paying higher premiums with income
above a specific threshold. The amount of the premium subsidy reduction
is an income-related monthly adjustment amount (IRMAA). The Internal
Revenue Service (IRS) transmits income tax return data to SSA for SSA
to determine the IRMAA. SSA uses the Form SSA-44 to determine if a
recipient qualifies for a reduction in the IRMAA. If affected Medicare
recipients believe SSA should use more recent tax data because of a
life-changing event that significantly reduces their income, they can
report these changes to SSA and ask for a new initial determination of
their IRMAA. The respondents are Medicare Part B and prescription drug
coverage recipients and enrollees with modified adjusted gross income
over a high-income threshold who experience one of eight significant
life-changing events.
Type of Request: Revision of an OMB-approved information
collection.
[[Page 19308]]
----------------------------------------------------------------------------------------------------------------
Average Estimated
Number of Frequency of burden per total annual
Modality of completion respondents response response burden
(minutes) (hours)
----------------------------------------------------------------------------------------------------------------
SSA-44 (Personal Interview in SSA field office). 140,378 1 30 70,189
SSA-44 (Paper Version).......................... 60,162 1 45 45,122
---------------------------------------------------------------
Totals...................................... 200,540 .............. .............. 115,311
----------------------------------------------------------------------------------------------------------------
Dated: April 21, 2017.
Naomi R. Sipple,
Reports Clearance Officer, Social Security Administration.
[FR Doc. 2017-08403 Filed 4-25-17; 8:45 am]
BILLING CODE 4191-02-P
