Application for Supplemental Security Income

Forms and Documents

Document Name	Status
Form SSA-8001-BK Application for Supplemental Security Income Form	Modified
Addendum - 0960-0444.docx Supplementary Document	2016-12-02
Supporting Statement - 0444.docx Supporting Statement A	2016-12-01

IC Document Collections

IC ID	Document Title	Status
224688	iClaim/MSSICS Other-Internal Screens/MSSICS	New
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: 201604-0960-008
Status: Historical Active	Previous ICR Reference No: 201503-0960-005
Agency/Subagency: SSA	Agency Tracking No:
Title: Application for Supplemental Security Income
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/15/2017
	Date Received in OIRA: 12/02/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/29/2020	36 Months From Approved	07/31/2018
Responses	701,185	0	1,335,666
Time Burden (Hours)	233,728	0	445,222
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:
	81 FR 31999	05/20/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 86374	11/30/2016
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
Application for Supplemental Security Income MSSICS/Signature Proxy
Application for Supplemental Security Income	SSA-8001-BK	Application For Supplemental Security Income
iClaim/MSSICS

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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	701,185	1,335,666	0	-237,055	-397,426	0
Annual Time Burden (Hours)	233,728	445,222	0	-79,018	-132,476	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: Yes

Burden Reduction Due to: Cutting Redundancy

Short Statement: The decrease in burden hours is due to the upcoming iClaim enhancement that allows a defined group of Title II disability applicants the ability to include an SSI deferred application with their Title II disability iClaim application. Based on the number of Title II disability iClaims filed in FY 2015 that resulted in concurrent applications (Title II disability and Title XVI SSI disability), we are estimating 400,000 Title II disability applicants will be able to include an SSI deferred application with their Title II disability iClaim application. Since iClaim is the collection method for these deferred applications, we are capturing these respondents in the iClaim burden information for OMB No. 0960-0618. However, we are adding a new collection method titled “iClaim/MSSICS” which represents the burden information for SSI deferred applications that originate in iClaim but require SSA to collect additional information from the SSA-8001-BK in MSSICS. We are providing an estimate of 162,945 respondents for this collection method based on the number of Title II disability iClaims filed in FY 2015 that resulted in concurrent applications and became SSI only claims due to technical ineligibility for Title II. We do not expect the burden response time to change for these respondents.

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Annual Cost to Federal Government: $7,740,296

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: 12/02/2016

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