Agency Information Collection Activities: Proposed Request and Comment Request, 19304-19308 [2017-08403]

Download as PDF 19304 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 (http://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 (http://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 ........................................................................................................ mstockstill on DSK30JT082PROD with NOTICES 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). VerDate Sep<11>2014 18:43 Apr 25, 2017 Jkt 241001 PO 00000 Frm 00108 Fmt 4703 Sfmt 4703 E:\FR\FM\26APN1.SGM 26APN1 19305 Federal Register / Vol. 82, No. 79 / Wednesday, April 26, 2017 / Notices 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 ............................................................................................................ mstockstill on DSK30JT082PROD with NOTICES 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 VerDate Sep<11>2014 18:43 Apr 25, 2017 Jkt 241001 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 PO 00000 Frm 00109 Fmt 4703 Sfmt 4703 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 E:\FR\FM\26APN1.SGM 26APN1 19306 Federal Register / Vol. 82, No. 79 / Wednesday, April 26, 2017 / Notices 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 mstockstill on DSK30JT082PROD with NOTICES 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 VerDate Sep<11>2014 18:43 Apr 25, 2017 Jkt 241001 PO 00000 Frm 00110 Fmt 4703 Sfmt 4703 E:\FR\FM\26APN1.SGM 26APN1 19307 Federal Register / Vol. 82, No. 79 / Wednesday, April 26, 2017 / Notices 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 ............................................................. mstockstill on DSK30JT082PROD with NOTICES 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). VerDate Sep<11>2014 18:43 Apr 25, 2017 Jkt 241001 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 PO 00000 Frm 00111 Fmt 4703 Sfmt 4703 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. E:\FR\FM\26APN1.SGM 26APN1 19308 Federal Register / Vol. 82, No. 79 / Wednesday, April 26, 2017 / Notices 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: mstockstill on DSK30JT082PROD with NOTICES 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 VerDate Sep<11>2014 18:43 Apr 25, 2017 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. Jkt 241001 • Title of Information Collection: Affidavit of Relationship (AOR) for Minors Who Are Nationals Of El Salvador, Guatemala, and Honduras. • OMB Control Number: 1405–0217. PO 00000 Frm 00112 Fmt 4703 Sfmt 4703 • 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 E:\FR\FM\26APN1.SGM 26APN1

Agencies

[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