Agency Forms Submitted to the Office of Management and Budget for Clearance

SOCIAL SECURITY ADMINISTRATION

Agency Forms Submitted to the Office of Management and Budget for

Clearance

Normally on Fridays, the Social Security Administration publishes a

list of information collection packages that will require submission to

the Office of Management and Budget (OMB) for clearance in compliance

with P.L. 96-511, as amended (P.L. 104-13 effective October 1, 1995),

The Paperwork Reduction Act. Since the last list was published in the

Federal Register on November 17, 1995, the following information

collections have been proposed or will require extension of the current

OMB approvals.

(Call the Reports Clearance Officer on (410) 965-4142 for a copy of

the form(s) or package(s), or write to her at the address listed

after the information collections.)

SSA Reports Clearance Officer: Charlotte S. Whitenight.

1. Quarterly Statistical Report on Recipients and Payments Under

State-administered Assistance Programs for Aged, Blind and Disabled

(Individuals and Couples) Recipients--0960-0130. The information

collected on the SSA-9741 is used to provide statistical data on

recipients and assistance payments under the SSI State-administered

State supplementation programs. These data are needed to complement the

data available for the federally administered programs under SSA and to

more fully explain the impact of the public income support programs on

the needy, aged, blind and disabled. The respondents are state agencies

who administer supplementary payment programs under SSI.

Number of Respondents: 23

Frequency of Response: 4 times annually

Average Burden Per Response: 1 hour

Estimated Annual Burden: 92 hours

2. Record of SSI Inquiry--0960-0140. The information collected on

form SSA-3462 is used to document the earliest possible filing date and

to determine potential eligibility for SSI benefits. The respondents

are individuals who inquire about SSI eligibility for themselves or

another individual.

Number of Respondents: 1,200,000

Frequency of Response: 1

Average Burden Per Response: 5 minutes

Estimated Annual Burden: 100,000

3. Request for Workers' Compensation/Public Disability

Information--0960-0098. The information collected on form SSA-1709 is

used to verify workers compensation and public disability benefits

payment amounts and to compute the correct reduction to the disability

insurance benefits. The respondents are state and local governments

and/or business that administer workers' compensation or other

disability benefits.

Number of Annual Responses: 140,000

Frequency of Response: As needed to verify changes in the amount of

workers compensation/public disability benefits

Average Burden Per Response: 15 minutes

Estimated Annual Burden: 35,000 hours

4. Employee Work Activity Questionnaire--0960-0483. The information

collected on form SSA-3033 is used to determine if a disability

claimant has or has not either engaged in substantial gainful activity

or received a non-specific subsidy. Such a determination is necessary

in evaluating a claimant's eligibility for Social Security disability

benefits. The respondents are current or former employers of disability

claimants.

Number of Respondents: 12,500

Frequency of Response: 1

Average Burden Per Response: 15 minutes

Estimated Annual Burden: 3,125 hours

5. Followup Survey for the Project Network Evaluation--0960-NEW.

Project Network is a demonstration project that tests alternative

approaches to assisting people with disabilities in

[[Page 61727]]

finding and maintaining employment. Followup information collected from

project participants (treatment and control group members) will be used

to evaluate the extent to which the different demonstration service-

delivery systems assisted people with disabilities to find and maintain

employment. The respondents are selected participants in the initial

Project Network survey.

Number of Respondents: 1,558

Frequency of Response: 1

Average Burden Per Response: 90 minutes

Estimated Annual Burden: 2,337 hours

Written comments and recommendations regarding these information

collections should be sent within 60 days from the date of this

publication, directly to the SSA Reports Clearance Officer at the

following address: Social Security Administration, DCFAM, Attn:

Charlotte S. Whitenight, 6401 Security Blvd., 1-B-22 Operations Bldg.,

Baltimore, MD 21235.

In addition to your comments on the accuracy of the agency's burden

estimate, we are soliciting comments on the need for the information;

its practical utility; ways to enhance its quality, utility and

clarity; and on ways to minimize burden on respondents, including the

use of automated collection techniques or other forms of information

technology.

The following information collections, which were published in the

Federal Register on October 6, 1995, have been submitted to OMB:

1. Request To Be Selected As Payee--0960-0014. The information

collected on form SSA-11-BK is used by the Social Security

Administration to help determine the proper payee for a person who

cannot receive his or her own Social Security benefits. The respondents

will be individuals who apply to receive Social Security benefits on

behalf of someone else.

Number of Respondents: 605,000.

Frequency of Response: 1.

Average Burden per Response: 10.5 minutes.

Estimated Annual Burden: 105,875 hours.

2. Disability Update Report--0960-0511. The information on form

SSA-455 is used by the Social Security Administration to determine if a

full medical continuing disability review (CDR) should be conducted.

The respondents will be Social Security disability insurance

beneficiaries who are scheduled to receive a CDR.

Number of Respondents: 431,200.

Frequency of Response: 1.

Average Burden Per Response: 15 minutes.

Estimated Annual Burden: 107,800 hours.

3. Statement Regarding Marriage--0960-0017. The information

collected via form SSA-753 is used by the Social Security

Administration to make determinations regarding entitlement to spouse's

benefits when a common law marriage is alleged. The respondents are

third parties who can supply evidence concerning the existence of a

common law marriage.

Number of Respondents: 40,000.

Frequency of Response: 1

Average Burden Per Response: 9 minutes.

Estimated Annual Burden: 6,000 hours.

4. State Contribution Return--0960-0041. The information on form

SSA-3961 is used by the Social Security Administration to identify and

account for all contributions due and paid by the states (or interstate

instrumentalities) under Section 218 of the Social Security Act. The

respondents are state agencies.

Number of Respondents: 117.

Frequency of Response: on occasion.

Average Burden Per Response: 3 minutes.

Estimated Annual Burden: 500 hours.

5. Statement of Death by Funeral Director--0960-0142. The

information collected on the SSA-721 is used by the Social Security

Administration to verify the death of an individual insured under the

Social Security Act and to determine if there is a survivor eligible

for a lump sum death payment. The respondents will be funeral directors

with knowledge of the death of a person insured for Social Security

benefits.

Number of Respondents: 900,000.

Frequency of Response: 1.

Average Burden Per Response: 3.5 minutes.

Estimated Annual Burden: 52,500 hours.

6. Annual Report of Earnings (long and short forms)--0960-0057. The

information on forms SSA-777 and SSA-7770 is used by the Social

Security Administration to determine the amount of yearly earnings of

beneficiaries so that the proper benefit amounts are paid to them. The

respondents will be beneficiaries under age 70 who have earned over the

exempt amount for the year and still received benefits.

Number of Respondents: (SSA-777)-200,000; (SSA-7770)-1,000,000.

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SSA-777 SSA-7770

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Frequency of Response.............. 1.................................... 1.

Average Burden per Response........ 17 minutes........................... 8 minutes.

Estimated Annual Burden............ 190,000 hours........................ 190,000 hours.

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7. Public Information Campaigns and News Releases--0960-0544. The

purpose of the public information campaigns and news releases is to

better inform the public about the programs and activities of the

Social Security Administration (SSA).

The information is used by SSA to determine media interest in

airing and printing the public information materials and news releases

and to determine which materials are used, how often, its

effectiveness, and the need for more local announcements. The

respondents are newspapers and public broadcasting systems such as

television, cable, and radio stations.

Number of Respondents: TV-500, Newspaper--500, Radio--1,500,

Cable--148.

Frequency of Response: Public Service Announcements--4, News

Releases--4, Educational Tapes--2.

Average Burden Per Response: 1 minute (solicitation card) 2 minutes

(business reply card).

Estimated Annual Burden: 298 hours.

8. Work Reintegration Study--0960-0543. The information on the two

forms used in this study will aid the Social Security Administration in

determining what steps it can take to help beneficiaries who are

disabled due to a back condition to return to work.

Number of Respondents: 1,500.

Frequency of Response: 1.

Average Burden Per Response: 1 hour.

Estimated Annual Burden: 1,500 hours.

Written comments and recommendations regarding these information

collections should be sent within 30 days of the date of this

publication. Comments may be directed to OMB and SSA at the following

addresses:

(OMB) Office of Management and Budget, OIRA, Attn: Laura Oliven,

New Executive Office Building, Room 10230, Washington, DC 20503.

[[Page 61728]]

(SSA) Social Security Administration, DCFAM, Attn: Charlotte S.

Whitenight, 6401 Security Blvd, 1-A-21 Operations Bldg., Baltimore, MD

21235.

Dated: November 21, 1995.

Charlotte Whitenight,

Reports Clearance Officer, Social Security Administration.

[FR Doc. 95-29139 Filed 11-30-95; 8:45 am]

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