Private Printing and Modification of Prescribed Application and Other Forms

Forms and Documents

Document Name	Status
Supporting Statement 0663 (Revised).doc Supporting Statement A	2014-01-06

IC Document Collections

IC ID	Document Title	Status
9711	Private Printing and Modification of Prescribed Application and Other Forms Instruction	Modified

ICR Details

OMB Control No: 0960-0663	ICR Reference No: 201309-0960-003
Status: Historical Active	Previous ICR Reference No: 201007-0960-012
Agency/Subagency: SSA	Agency Tracking No:
Title: Private Printing and Modification of Prescribed Application and Other Forms
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/30/2014
	Date Received in OIRA: 01/09/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2017	36 Months From Approved	04/30/2014
Responses	225	0	150
Time Burden (Hours)	30	0	20
Cost Burden (Dollars)	0	0	0

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Abstract: Regulation 20 CFR 422.527 states that any person, institution, or organization wishing to privately reproduce, duplicate, or print any of SSA's applications (such as forms) must first obtain written approval from SSA to do so. The respondent are persons or organizations wishing to privately reproduce or print any of SSA's applications.

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Authorizing Statute(s): US Code: 42 USC 1320b¿10 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:
	78 FR 62932	10/22/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 79723	12/31/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Private Printing and Modification of Prescribed Application and Other Forms

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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	225	150	0	0	75	0
Annual Time Burden (Hours)	30	20	0	0	10	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: There has been a decrease in burden hours. The decrease stems from receiving fewer requests within the last three years.

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Annual Cost to Federal Government: $928

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

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: 01/09/2014

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