Daily Rules, Proposed Rules, and Notices of the Federal Government


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 to and one 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, Social Security Administration, DCRDP, Attn: Reports Clearance Director, 107 Altmeyer Building, 6401 Security Blvd., Baltimore, MD 21235, Fax: 410-966-2830, Email 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 November 23, 2012. Individuals can obtain copies of the collection instruments by writing to the above email address.

1.Reporting Changes that Affect Your Social Security Payment--20 CFR 404.301-305, 404.310-311, 404.330-.333, 404.335-.341, 404.350-.352, and 404.468--0960-0073.When Social Security benefits recipients experience a change that could affect their payments, they must report these changes to SSA. Title II beneficiaries in this category use form SSA-1425 to report the relevant information to SSA; the agency then determines if the respondents continue to be entitled to benefits, and if so, the proper amount of these benefits. The respondents are Social Security beneficiaries receiving Title II SSA retirement, disability, or survivor's auxiliary benefits who need to report an event that could affect their payments.

Type of Request:Revision of an OMB-approved information collection.

2.Privacy and Disclosure of Official Records and Information; Availability of Information and Records to the Public--20 CFR 401.40(b)&(c), 401.55(b), 401.100(a), 402.130, 402.185--0960-0566.SSA has established methods for the public to: (1) Access their SSA records; (2) allow SSA to disclose records; (3) correct or amend their SSA records; (4) consent to release of their records; (5) request records under the Freedom of Information Act (FOIA); and (6) request SSA waive or reduce fees normally charges for release of FOIA. SSA often collects the necessary information for these requests through a written letter, with the exception of the consent for release of records, for which there is the Form SSA-3288. The respondents are individuals requesting access to, correction of, or disclosure of SSA records.

Type of Request:Revision of an OMB-approved information collection.

3.Claimant Statement about Loan of Food or Shelter; Statement about Food or Shelter Provided to Another--20 CFR 416.1130-416.1148--0960-0529.SSA uses Forms SSA-5062 and SSA-L5063 in the administration of the Supplemental Security Income (SSI) program. SSA bases an SSI claimant or recipient's eligibility on need. We measure need by the amount of income an individual receives. Income includes other persons providing in-kind support and maintenance in the form of food and shelter to SSI applicants or recipients. SSA uses Forms SSA-5062 and SSA-L5063 to obtain statements about food or shelter provided to SSI claimants or recipients. SSA uses this information to determine whether food or shelters are bona fide loans or income for SSI purposes. This determination may affect a claimant or recipient's eligibility for SSI and the amount of SSI payments. The respondents are claimants and recipients for SSI payments, and individuals who provide loans of food or shelter to them.

Type of Request:Revision of an OMB-approved information collection.

4.Site Review Questionnaire for Volume and Fee-for-Service Payees and Beneficiary Interview Form--20 CFR 404.2035, 404.2065, 416.665, 416.701, and 416.708--0960-0633.SSA asks organizational representative payees to complete Form SSA-637, the Site Review Questionnaire for Volume and Fee-for-Service Payees, to provide information on how they carry out their responsibilities, including how they manage beneficiary funds. SSA then obtains information from the beneficiaries these organizations represent via Form SSA-639, Beneficiary Interview Form, to corroborate the payees' statements. Due to the sensitivity of the information, SSA employees always complete the forms based on the answers respondents give during the interview. The respondents are individuals, State and local governments, non-profit and for-profit organizations serving as representative payees, and the beneficiaries they serve.

Type of Request:Revision of an OMB-approved information collection.

5.Certification of Prisoner Identity Information--20 CFR 422.107-- 0960-0688.Inmates of Federal, State, or local prisons may need a Social Security card as verification of their Social Security number for school or work programs, or as proof of employment eligibility upon release from incarceration. Before SSA can issue a replacement Social Security card, applicants must show SSA proof of their identity. People who are in prison for an extended period typically do not have current identity documents. Therefore, under formal written agreement with the correctional institution, SSA allows prison officials to verify the identity of certain incarcerated U.S. citizens who need replacement Social Security cards. Information prison officials provide comes from the official prison files, sent on correctional facility letterhead. SSA uses this information to establish the applicant's identity in the replacement Social Security card process. The respondents are prison officials who certify the identity of prisoners applying for replacement Social Security cards.

Type of Request:Extension of an OMB-approved Information Collection.


SSA submitted the information collections below to OMB for clearance. Your comments regarding the information collections would be most useful if OMB and SSA receive them 30 days from the date of this publication. To be sure we consider your comments, we must receive them no later than October 24, 2012. Individuals can obtain copies of the OMB clearance packages by writing

1.Statement of Care and Responsibility for Beneficiary--20 CFR 404.2020, 404.2025, 408.620, 408.625, 416.620, 416.625--0960-0109.SSA uses the information from Form SSA-788 to verify payee applicants' statements of concern and to identify other potential payees. SSA is concerned with selecting the most qualified representative payee who will use Social Security benefits in the beneficiary's best interest. SSA considers factors such as the payee applicant's capacity to perform payee duties, awareness of the beneficiary's situation and needs, demonstration of past and current concern for the beneficiary's well-being, etc. If the payee applicant does not have custody of the beneficiary, SSA will obtain information from the custodian for evaluation against information provided by the applicant. Respondents are individuals who have custody of the beneficiary in cases where someone else has filed to be the beneficiary's representative payee.

This is a correction notice:SSA published the incorrect burden information for this collection at 77 FR 47688, on 08/09/12. We are correcting this error here.

Type of Request:Revision of an OMB-approved information collection.

2.Function Report Adult--Third Party--20 CFR 404.1512 & 416.912--0960-0635.Individuals receiving or applying for Social Security Disability Insurance (SSDI) or SSI provide SSA with medical evidence and other proof SSA requires to prove their disability. SSA, and Disability Determination Services (DDS) on our behalf, collect this information using Form SSA-3380-BK. We use the information to document how claimant's disabilities affect their ability to function, and to determine eligibility for SSI and SSDI claims. The respondents are third parties familiar with the functional limitations (or lack thereof) of claimants who apply for SSI and SSDI benefits.

Dated: September 19, 2012. Faye Lipsky, Reports Clearance Director, Social Security Administration.