20 CFR 404.408(e)
Introduction/Authoring Laws and Regulations
Section 224 of the Social Security Act provides for an offset (reduction) of Social Security Disability Insurance benefits (SSDI) when the disabled workers also receive Workers' Compensation (WC) or Public Disability benefits (PDB). 20 CFR 404.408(e) of the Code of Federal Regulations states "the individual(s) may be required...to furnish evidence as requested by the Administration" of the WC/PDB benefits they receive. If the disabled workers are unable to provide evidence verifying the amount of WC/PDB paid, the Social Security Administration (SSA) must obtain such information from the Federal, State or local agency, self-insured public or private employer, or insurance carrier administering the WC/PDB.
SSA uses Form SSA-1709 to obtain WC/PDB verification in order to correctly impose, adjust, or terminate offset of SSDI benefits. SSA considers the disabled workers the primary sources of WC/PDB verification, and if they provide the necessary evidence (e.g., award notice, benefit check, etc.), SSA does not use this form. If the disabled worker cannot provide the required verification, the most reliable sources for verification are the entities providing or paying the benefits. The respondents are Federal, State, and local agencies, insurance carriers and public or private self-insured companies administering WC/PDB.
Use of Information Technology to Collect the Information
SSA did not create an electronic version of the SSA-1709 under the agency’s Government Paperwork Elimination Act, as we require the disabled worker’s wet signature, authorizing release of the WC/PDB information. However, the form is on SSA’s website for disabled workers to print, sign, and mail to SSA. SSA then mails the form to the entity (insurance carrier, WC Board, etc.) for completion of all information about WC/PDB benefit payment. The entity then signs and dates the form and returns the form to SSA.
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 collect similar data.
Minimizing Burden on Small Respondents
This collection does not significantly affect a substantial number of small businesses or other small entities.
Consequence of Not Collecting Information or Collecting it Less Frequently
SSA’s failure to collect the information could result in incorrect payments. In addition, since SSA collects this information on an as needed basis, we cannot collect it less frequently. There are no technical or legal obstacles to burden reduction.
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.
Solicitation of Public Comment and Other Consultations with the Public
The 60-day advance Federal Register Notice published on April 10, 2012, at 77 FR 21616, and we received no public comments. SSA published the second Notice on July 9, 2012, at 77 FR 40400. If we receive comments in response to the 30-day Notice, we will forward them to OMB. We did not consult with the public in the revision of this form.
Payment or Gifts to Respondents
SSA provides no payment or gifts to the respondents.
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.
Justification for Sensitive Questions
The information collection does not contain any questions of a sensitive nature.
Estimates of Public Reporting Burden
Approximately 120,000 respondents use Form SSA-1709 annually. We estimate an average response time of 15 minutes for 30,000 burden hours. The total burden represents burden hours, and SSA did not calculate a separate cost burden.
Annual Cost to the Respondents (Other)
This collection does not impose a known cost burden on the respondents.
Annual Cost To Federal Government
The annual cost to the Federal Government is approximately $600,000. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.
Program Changes or Adjustments to the Information Collection Request
There are no changes in the public reporting burden.
Plans for Publication Information Collection Results
SSA will not publish the results of the information collection.
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.
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).
Collections of Information Employing Statistical Methods
SSA does not use statistical methods for this collection.
| File Type | application/msword |
| File Title | Title of Information Collection and Form Number(s) |
| Author | Naomi |
| Last Modified By | 889123 |
| File Modified | 2012-07-11 |
| File Created | 2012-07-11 |