Application for Supplemental Security Income

Forms and Documents

Document Name	Status
Form SSA-8001-BK Application for Supplemental Security Income Form	New
Addendum to supporting statement 0444.doc Supplementary Document	2009-05-13
Supplemental Security Income Record and Special Veterans Benefits, Social Security Administration, Office of Systems, Office of Disability and Supplemental Security Income Systems (ODSSIS).htm Supplementary Document	2009-04-08
Supporting Statement 0444 revised.doc Supporting Statement A	2009-04-14

IC Document Collections

IC ID	Document Title	Status
9319	Application for Supplemental Security Income MSSICS Other-MSSICS Screen	Modified
188727	Application for Supplemental Security Income Form	New
188726	Application for Supplemental Security Income MSSICS/Signature Proxy Other-MSSIC/Signature Proxy	New
188105	February 2009 Brief Survey of Title XVI Applicants Other-phone survey	Removed

ICR Details

OMB Control No: 0960-0444	ICR Reference No: 200904-0960-004
Status: Historical Active	Previous ICR Reference No: 200902-0960-018
Agency/Subagency: SSA	Agency Tracking No:
Title: Application for Supplemental Security Income
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/21/2009
	Date Received in OIRA: 04/14/2009
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2012	36 Months From Approved	05/31/2009
Responses	967,531	0	1,200,910
Time Burden (Hours)	238,900	0	286,524
Cost Burden (Dollars)	0	0	0

---

Abstract: Form SSA-8001-BK collects information SSA uses to determine applicant’s eligibility for SSI, and the amount of SSI benefits. SSA employees secure this information during interviews conducted with members of the public who wish to file for SSI benefits. This form is used for two purposes: (1) To formally deny Supplemental Security Income benefits for non-medical reasons when information provided by the applicant results in ineligibility OR (2) to establish a disability claim, but defer the complete development of non-medical issues until the disability is approved. The respondent’s are recipients for Supplemental Security Income benefits.

---

Authorizing Statute(s): US Code: 42 USC 1383 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 75488	12/11/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 7506	02/17/2009
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Application for Supplemental Security Income MSSICS
Application for Supplemental Security Income MSSICS/Signature Proxy
Application for Supplemental Security Income	SSA-8001-BK	Application For Supplemental Security Income
February 2009 Brief Survey of Title XVI Applicants

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	967,531	1,200,910	0	-46,150	-187,229	0
Annual Time Burden (Hours)	238,900	286,524	0	-769	-46,855	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: There has been a decrease in the number of burden hours, because the number of respondents using Form SSA-8001-BK (short application) has decreased due to the increased usage of Form SSA-8000-BK (full application

---

Annual Cost to Federal Government: $149,002

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 04/14/2009

---