OMB 0960-0024 Supporting Statement (revised)

Supporting Statement for Form SSA-787

Physician’s/Medical Officer’s Statement of Patient’s Capability to Manage Benefits

20 CFR 404.2015 and 416.615

OMB No. 0960-0024

A. Justification

1. Introduction/Authoring Laws and Regulations

The Social Security Administration (SSA) appoints representative payees on behalf of beneficiaries if we determine the beneficiaries should not receive their own benefits because they are incapable of managing those benefits. 20 CFR 404.2015 and 416.615 of the Code of Federal Regulations require medical evidence to determine if a beneficiary is capable of managing or directing the management of benefits payments. Sections 205(j), 807, and 1631(a)(2) of the Social Security Act (Act) specifically state the Commissioner of the SSA has the authority to appoint a representative payee on behalf of a beneficiary. SSA is responsible for finding and appointing the best-qualified payee who is available and willing to serve.

2. Description of Collection

SSA appoints a representative payee in cases where we determine beneficiaries are not capable of managing their own benefits. In those instances, we require medical evidence to determine the beneficiaries’ capability of managing or directing their benefit payments. SSA collects medical evidence on Form SSA-787 to (1) determine beneficiaries’ capability or inability to handle their own benefits, and (2) assist in determining the beneficiaries’ need for a representative payee. The respondents are the beneficiary’s physicians or medical officers of the institution in which the beneficiary resides.

2. Use of Information Technology to Collect the Information

This is a paper information collection available as PDF print-only form on the SSA Intranet. SSA did not create an electronic version of Form SSA-787 under the agency’s Government Paperwork Elimination Act, because we pre-fill the form with information specific to the beneficiary before sending it to the respondents. Since SSA needs to generate these forms with beneficiary-specific information each time we use it, we cannot make it available electronically for the medical professionals.

2. 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-787, the agency could not collect the necessary medical evidence for use in determining if beneficiaries are capable of managing their funds with or without a representative payee. As we only generate and use this form on an as-needed basis, SSA cannot collect the information 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 June 23, 2015, at 80 FR 36031, and we received no public comments. The 30-day FRN published on August 25, 2015 at 80 FR 51647. If we receive any comments in response to this Notice, we will forward them to OMB.

8. Payment or Gifts to Respondents

SSA does not provide payments or gifts to the respondents.

8. 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.

8. Justification for Sensitive Questions

The information collection contains some questions that may lead to the disclosure of sensitive information since the beneficiary's medical history may be included in the collection. However, this information is necessary to determine if a beneficiary can receive benefits directly.

8. Estimates of Public Reporting Burden

Modality of Completion	Number of Respondents	Frequency of Response	Average Burden Per Response (minutes)	Estimated Total Annual Burden (hours)
SSA-787	120,000	1	10	20,000

The total burden for this ICR is 20,000 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 $184,800. This estimate is a projection of the costs for printing and distributing the collection instrument, 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.

3