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 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

(SSA), 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 27, 2012. Individuals can obtain copies of the collection instruments by writing to the above email address.

1.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.Under the Privacy and Disclosure of Official Records and Information, SSA established methods for the public to: (1) Access to their SSA records; (2) disclosure of SSA 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); (6) and waive or reduce fees normally charged for release of FOIA records. 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.

2.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 and/or shelter provided to SSI claimants or recipients. SSA uses this information to determine whether food or shelter are bona fide loans or should be counted as 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.

II. 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 29, 2012. Individuals can obtain copies of the OMB clearance packages by writing

1.Statement of Employer--20 CFR 404.801-404.803--0960-0030.When workers report they were paid wages but cannot provide proof of those earnings, and the wages do not appear in SSA's records of earnings, SSA uses form SSA-7011-F4 to document the alleged wages. Specifically, the agency uses the form to resolve discrepancies in the individual's Social Security earnings record and to process claims for Social Security benefits. We only send Form SSA-7011-F4 to employers if we are unable to locate the earnings information in our own records. The respondents are employers who can verify wage allegations made by wage earners.

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

2.Request for Deceased Individual's Social Security Record--20 CFR 402.130--0960-0665.When a member of the public requests an individual's Social Security record, SSA needs the name and address of the requestor as well as a description of the requested record to process the request. SSA uses the information the respondent provides on Form SSA-711, or via an Internet request through SSA's electronic Freedom of Information Act (eFOIA) Web site, to (1) verify the wage earner is deceased and (2) access the correct Social Security record. Respondents are members of the public requesting deceased individuals' Social Security records.

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

Dated: September 25, 2012. Faye Lipsky, Reports Clearance Director, Social Security Administration.