supporting_statement_0324 (revised)

Supporting Statement for Form SSA-L8050-U3

Supplemental Security Income Claim Information Notice

20 CFR, Subpart B, 416.210

OMB No. 0960-0324

A. Justification

1. Introduction/Authoring Laws and Regulations

Section 1611(e)(2) of the Social Security Act (the Act) and Section 20 CFR, Subpart B, 416.210 of the Code of Federal Regulations authorize the Commissioner of the Social Security Administration (SSA) to collect the information Form SSA-L-8050-U3 provides. In order to meet the eligibility requirements for supplemental security income (SSI), the statute requires that an individual file for and obtain all payments (annuities, pensions, disability benefits, veteran's compensation, etc.) for which they are eligible. The regulations state, in part, that an individual is not eligible for SSI benefits if they do not apply for all other benefits for which they may be eligible.

2. Description of Collection

SSI supplements other income an individual has available SSA uses Form SSA–L8050–U3 to collect information on whether an SSI recipient is using all sources of potential income (annuities, pensions, disability benefits, veteran’s compensation, etc.) for their own support. SSI supplements other income an individual has available. Respondents are SSI applicants or recipients who may be eligible for benefits from public or private programs. SSA mails Form SSA-L8050-U3 to applicants or recipients when they apply for benefits.

3. Use of Information Technology to Collect the Information

SSA did not create an electronic version of form SSA-L8050-U3 under the agency’s Government Paperwork Elimination Act (GPEA) plan because only 7,500 respondents complete the form. This is less than the GPEA cut-off of 50,000.

4. Why We Cannot Use Duplicate Information

The nature of the information we are collecting and the manner in which we are collecting it preclude duplication. SSA does not use another collection instrument to obtain similar data.

5. Minimizing Burden on Small Respondents

This collection does not significantly affect small businesses or other small entities.

6. Consequence of Not Collecting Information or Collecting it Less Frequently

If we did not use Form SSA–L8050–U3, we would not be able to conduct timely reviews of other potential sources of income or benefits, which could result in overpayments to claimants or recipients. Because we only collect the information on an as needed basis, we cannot collect it less frequently.

There are no technical or legal obstacles to burden reduction.

7. Special Circumstances

There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.

8. Solicitation of Public Comment and Other Consultations with the Public

The 60-day advance Federal Register Notice published on November 16, 2011, at

76 FR 71105, and we received no public comments. The 30-day FRN published on January 31, 2012 at 77 FR 4854. If we receive any comments in response to this Notice, we will forward them to OMB. We did not consult with the public in the revision of this form.

9. Payment or Gifts to Respondents

SSA does not provide payments or gifts to the respondents.

10. Assurances of Confidentiality

SSA protects and holds confidential the information it collects in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974), and OMB Circular No. A-130.

11. Justification for Sensitive Questions

The information collection does not contain any questions of a sensitive nature.

12. Estimates of Public Reporting Burden

Collection instrument	Number of responses	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-L-8050-U3	7,500	1	10	1,250

The total burden for this ICR is 1,250 hours. This figure represents burden hours, and we did not calculate a separate cost burden.

13. Annual Cost to the Respondents (Other)

This collection does not impose a known cost burden on the respondents.

14. Annual Cost To Federal Government

The annual cost to the Federal government is approximately $23,100. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.

15. Program Changes or Adjustments to the Information Collection Request

There are no changes to the public reporting burden.

16. Plans for Publication Information Collection Results

SSA will not publish the results of the information collection.

17. Displaying the OMB Approval Expiration Date

OMB granted SSA an exemption from the requirement to print the OMB expiration date on its program forms. SSA produces millions of public-use forms with life cycles exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis), OMB granted this exemption so SSA would not have to destroy stocks of otherwise useable forms with expired OMB approval dates, avoiding Government waste.

18. Exceptions to Certification Statement

SSA is not requesting an exception to the certification requirements at 5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b)(3).

B. Collections of Information Employing Statistical Methods

SSA does not use statistical methods for this information collection.