Application for Supplemental Security Income

Forms and Documents

Document Name	Status
Form SSA-8001-BK Application for Supplemental Security Income Form	Modified
Addendum 0444 (revised).docx Supplementary Document	2015-05-27
Supporting Statemet 0444 (revised).doc Supporting Statement A	2015-06-29

IC Document Collections

IC ID	Document Title	Status
9319	Application for Supplemental Security Income MSSICS Other-MSSICS Screen	Removed
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: 201503-0960-005
Status: Historical Active	Previous ICR Reference No: 201112-0960-002
Agency/Subagency: SSA	Agency Tracking No:
Title: Application for Supplemental Security Income
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: 07/06/2015
	Date Received in OIRA: 05/28/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2018	36 Months From Approved	08/31/2015
Responses	1,335,666	0	1,360,000
Time Burden (Hours)	445,222	0	335,920
Cost Burden (Dollars)	0	0	0

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Abstract: SSA collects information on the SSA-8001-BK to determine an applicant's eligibility for SSI and the SSI payment amounts. SSA employees also collect this information during interviews with members of the public who wish to file for SSI. SSA uses the information for two purposes: (1) To formally deny SSI for non-medical reasons when information the applicant provides results in ineligibility; or (2) to establish a disability claim, but defer the complete development of non-medical issues until SSA approves the disability. The respondents are recipients for SSI benefits.

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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:
	80 FR 14432	03/19/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 29787	05/22/2015
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 2

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	1,335,666	1,360,000	0	-1,006,400	982,066	0
Annual Time Burden (Hours)	445,222	335,920	0	-251,600	360,902	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 is an increase in burden hours, this change stems from an increase in the number of respondents applying for benefits.

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Annual Cost to Federal Government: $11,017,777

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: 05/28/2015

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