State Agency Report of obligations for SSA Disability Programs--SSA-4513 & SSA-4513-SUP

Instructions for Completion of Form SSA-4513

Heading
Enter official name of agency, State, fiscal year being
reported, and the period from October 1 of that fiscal
year through the end of the calendar quarter for
which you are reporting.

Column Entries
Column A, Disbursements - Enter cumulative
disbursements through the end of report period.
Column B, Unliauidated Obligations - Enter amount
of all unliquidated obligations as of the ending date
of report period.
Column C, Total Obligations - Automatically
calculated (sum of Column A and B) to reflect the
total cumulative obligations effective at the end of
report period.

Line Entries
Line 1, Personnel Costs - Enter the salary costs and
h n g e benefits paid to personnel for time devoted to
SSA disability programs.
Line 2. Medical Costs - Automatically calculated
(sum of 2a and 2b) to reflect the total costs incurred
for the purchase of CEIMER for all SSA disability
program titles.
Line 2a, Consultative Examinations Automatically calculated (sum of 1 thru 3)
to reflect the total cost for CE's.

Line 2b Medical Evidence of Record Automatically calculated to reflect the total
cost for MER (sum of 1 thru 3).
Line 2b(l-3) DI, SSI, Concurrent Claims Enter costs incurred for the purchase of
MER by SSA disability program title.
Line 3. Indirect Costs - Enter total indirect charges
which were obligated in accordance with approved
State-wide cost allocation agreements or charged by
the State Parent Agency.
Line 4. All Other Nonoersonnel Costs Automatically calculated from entries made in the
categories listed in 4(a through j).
Line 4(a thru i) - Enter amount obligated for
each category listed under All Other
Nonpersonnel Costs per POMS DI
39506.809.E.
Line 5, Total - Automatically calculated to reflect the
sum of the line entries for columns A, B, and C.
Line 6. Cumulative Obligational Authorization Enter amount reflected on the latest SSA-872
authorized for the report period.
Line 7. SSA-871 Attached - Self-explanatory
Signature/Title/Date- This form must be signed by
person (name and official title) authorized to submit
estimates of anticipated costs and reports of actual
expenditures (per acceptable certificate of authority).

Line 2atl-3) DI. SSI, Concurrent ClaimsEnter costs incurred for the purchase of
CE's by SSA disability program title.

Paperwork Reduction Act Statements
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This information collection meets the clearance requir ments of 44 U.S.C. ' 3507, as amended by section 2 of the
Pa erwork Reduct' Act of
5. You are not r ired to answer
questions unle
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Thefollowing revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget control number. We estimate that it will take about 90
minutes to read the instructions, gather the facts, and answer the questions. You may send
comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD
21235-6401. Send & comments relating to our time estimate to this address, not the
completed form.