Authorization for the Social Security Administration to Obtain Personal Information

Forms and Documents

Document Name	Status
Form SSA-8510 SSA-8510 – Title II and Title XVI general evidence (paper version) Form	New
Form SSA-8510 SSA-8510 – Medicare Subsidy Quality Review (paper version) Form	New
Addendum - SSA-8510.docx Supplementary Document	2015-07-07
Supporting Statement - Form-8510.docx Supporting Statement A	2015-07-07

IC Document Collections

IC ID	Document Title	Status
216304	SSA-8510 – Title II and Title XVI general evidence (MSSICS version) Other-Internal Screen	New
216303	SSA-8510 – Title II and Title XVI general evidence (paper version) Form	New
216301	SSA-8510 – Medicare Subsidy Quality Review (paper version) Form	New

ICR Details

OMB Control No: 0960-0801	ICR Reference No: 201504-0960-011
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: SSA	Agency Tracking No:
Title: Authorization for the Social Security Administration to Obtain Personal Information
Type of Information Collection: Existing collection in use without an OMB Control Number	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/18/2015
	Date Received in OIRA: 07/07/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2018	36 Months From Approved
Responses	163,445	0	0
Time Burden (Hours)	13,621	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: SSA uses the information we gather on the SSA-8510 and accompanying Modernized Supplemental Security Income Claims System (MSSICS) screens to determine if individuals are eligible for specific Social Security or Medicare Part D benefits, or for Supplemental Security Income (SSI) payments. SSA uses the SSA-8510 to contact a public or private custodian of records and request evidence information to support a benefit application or payment continuation. We ask for evidence information such as the following: Age requirements (e.g. birth certificate, court documents); Insured status (e.g. earnings, employer verification); Marriage or divorce information; Pension Offsets; Wages verification; Annuities; Property information; Benefit verification from a State agency or third party; Immigration status (rare instances); Income verification from public agencies or private individuals; Unemployment benefits; Insurance Policies. If the custodian requires a signed authorization from the individual(s) whose information SSA requests, SSA provides the custodian with a copy of the SSA-8510. Once the respondent completes the SSA 8510, either using the paper form, or through a personal interview during which an SSA employee completes the MSSICS version, SSA uses the form as the authorization to obtain personal information regarding the respondent from third parties until the authorizing person (respondent) revokes the permission of its usage. The collection is voluntary; however, failure to verify the individuals' eligibility can prevent SSA from making an accurate and timely decision for their benefits. The respondents are individuals who file for, or currently receive, Social Security benefits, SSI payments, or Medicare Part D subsidies.

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Authorizing Statute(s): US Code: 42 USC 1383 Name of Law: Social Security Act
   US Code: 42 USC 405 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 26605	05/08/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 38795	07/07/2015
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
SSA-8510 – Title II and Title XVI general evidence (MSSICS version)
SSA-8510 – Medicare Subsidy Quality Review (paper version)	SSA-8510	Authorization for the Social Security Administration to Obtain Personal Information
SSA-8510 – Title II and Title XVI general evidence (paper version)	SSA-8510	Authorization for the Social Security Administration to Obtain Personal Information

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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	163,445	0	0	163,445	0	0
Annual Time Burden (Hours)	13,621	0	0	13,621	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This form is currently in use under OMB Number 0960-0707 under which we only reported the Medicare Part D usage; therefore, our estimate for general purposes is in use without an OMB number. Since we are currently reporting the expanded usage for general purposes, which increases the public burden, we are also requesting a new OMB number as our information collection for 0960-0707 covers only Medicare, and we currently use this form for other SSA programs as well (as indicated in #2 of the Supporting Statement). In addition, we are also including a new electronic version of the SSA 8510 in MSSICS, which also changes the total burden.

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Annual Cost to Federal Government: $1,281

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: 07/07/2015

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