Application for Supplemental Security Income

Forms and Documents

Document Name	Status
Form SSA-8001-BK Application for Supplemental Security Income Form	Modified
SSA-8001-BK - New MSSICS Screen.doc Supplementary Document	2009-09-17
SSA-8001-BK - Marked Up Revised Copy.pdf Supplementary Document	2009-09-17
0960-0444 Change Request - Sept 2009.doc Justification for No Material/Nonsubstantive Change	2009-09-17

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	Modified
188726	Application for Supplemental Security Income MSSICS/Signature Proxy Other-MSSIC/Signature Proxy	Modified

ICR Details

OMB Control No: 0960-0444	ICR Reference No: 200909-0960-004
Status: Historical Active	Previous ICR Reference No: 200907-0960-001
Agency/Subagency: SSA	Agency Tracking No:
Title: Application for Supplemental Security Income
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/18/2009
	Date Received in OIRA: 09/17/2009
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2012	05/31/2012	05/31/2012
Responses	967,531	0	967,531
Time Burden (Hours)	238,900	0	238,900
Cost Burden (Dollars)	0	0	0

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Abstract: PL 110-328, The SSI Extension for Disabled and Elderly Refugees Act, temporarily extends the 7-year SSI eligibility period for certain refugees, asylum seekers, and other humanitarian immigrants, including victims of human trafficking, to 9 years. The 2-year extension applies to those aliens who were suspended or terminated from August 22, 1996 to September 30, 2008, due to the expiration of the 7-year eligibility period. SSA plans to add five prompts to a page in the SSI MSSICS screens in order to collect information about this category of refugees, asylum seekers, and other humanitarian immigrants. The documentation is used to support additional payments to certain refugees, asylum seekers, and other humanitarian immigrants. Please see the "Add/Edit Supporting Statement and Other Documents" page for details.

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

Citations for New Statutory Requirements: None

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

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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

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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

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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	967,531	0	0	0	0
Annual Time Burden (Hours)	238,900	238,900	0	0	0	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: No

Burden Reduction Due to:

Short Statement: We are increasing the total annual burden to reflect the addition of the additional financial permissions questions to both the paper and MSSICS versions of this form. SSA estimates it will take the respondent an average of one minute to complete the financial permission (which includes time for our staff to explain the permission), for an estimated increase in the burden by 16,125 hours. Therefore, the new estimated annual burden for this ICR is 255,025.

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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

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Common Form ICR:  No

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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: 09/17/2009

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