Supporting Statement - 0448

Supporting Statement for SSA-2490-BK,

Application for Benefits Under a U.S.

International Social Security Agreement

20 CFR 404.1925

OMB No. 0960-0448

A. Justification

1. Sections 205(a), 205(c)(2), and 233 of the Social Security Act (Act) authorize the President to enter into bilateral Social Security agreements between the United States and foreign countries. These agreements (Totalization agreements), provide that the Social Security Administration (SSA) may determine retirement, survivors, disability, and derivative benefits on combined periods of coverage from the two countries. 20 CFR 404.1925 of the Code of Federal Regulations provides that if an applicant files for benefits from one country, that application can constitute an application for benefits from the other country, provided the applicant express the intent to file for benefits from the other country. To assist the other country in determining the right to benefits under its laws, or in identifying coverage under its social insurance system, each country obtains specific information from the applicant and then exchanges the material with the other country.

2. Description of Collection

SSA collects information using Form SSA-2490-BK to determine entitlement to Social Security benefits from the United States, or from a country that enters into a Totalization agreement with the United States. The United States signs new agreements whenever necessary and we may create Totalization agreements with several new countries in any given year, and we update this information collection accordingly. For instance, the United States signed new agreements with Hungary on February 3, 2015; Brazil on June 30, 2015; and Iceland on September 27, 2016. The agreement with Hungary entered into force on September 1, 2016. SSA is including Hungary, Brazil and Iceland in this OMB renewal. We expect the agreements with Brazil and Iceland will enter into force by the end of the fiscal year 2017. Including Hungary, Brazil and Iceland under OMB No. 0960‑0448 will permit field office personnel to collect the required information from individuals applying for OASDI benefits under these agreements.

Applicants applying for benefits from the United States under any Social Security agreement must complete Form SSA-2490-BK through a U.S. claims-taking facility, such as a Social Security field office (FO) or Foreign Service Post, which is responsible for assisting them with the application. Applicants filing for foreign benefits at a U.S. claims taking facility will also complete Form

SSA-2490-BK. This does not apply to applicants filing for foreign benefits under the agreements with Australia, Canada, Czech Republic, Japan, South Korea, and Spain, because the information is already on file with foreign governments. The respondents are individuals applying for Old Age Survivors and Disability Insurance (OASDI) benefits from the United States or from a Totalization agreement country.

2. Use of Information Technology to Collect the Information

Form SSA-2490-BK is available to SSA FOs through the Modernized Claims System version (MCS). FOs use this form when a person files for U.S. retirement or disability totalization benefits only, or U.S. retirement or disability totalization benefits concurrently for foreign benefits. Form SSA-2490-BK is also available through SSA’s Intranet website as a print-only PDF through the Totalization Resource Kit.

In accordance with the agency’s Government Paperwork Elimination Act plan, SSA created an electronic version of form SSA-2490-BK. Based on our data, we estimate approximately 90% of respondents under this OMB number use the electronic version.

2. Why We Cannot Use Duplicate Information

The nature of the information we collect and the manner in which we collect it precludes duplication. SSA does not use another collection instrument to obtain similar data.

5. Minimizing Burden on Small Respondents

This collection does not 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-2490-BK, SSA would be unable to determine eligibility of applicants who expresses a desire to file for benefits under a totalization agreement. Additionally, the agency would be unable to fulfill obligations to obtain information that our agreement partners need to determine eligibility for benefits under their systems. Because we only collect the information on an as needed basis, we cannot collect it less frequently.

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 April 26, 2017, at

82 FR 19304, and we received no public comments. The 30-day FRN published on July 5, 2017 at 82 FR 31132. 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 does not contain any questions of a sensitive nature.

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-2490-BK (MCS)	15,030	1	30	7,515
SSA-2490-BK (paper)	2,120	1	30	1,060
Totals	17,150			8,575

The total burden for this ICR is 8,575 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 $282,975. This estimate is a projection of the costs for printing and distributing the collection instrument, and for collecting the information.

15. Program Changes or Adjustments to the Information Collection Request

The burden change stems from the inclusion of the agreements with the United States signed with Hungary, Brazil, and Iceland (mentioned in #2 above).

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.