Supporting Statement - 0019

Supporting Statement for Form SSA-781

Certificate of Responsibility For Welfare and Care of Child Not in Applicant's Custody

20 CFR 404.330, 404.339-404.341 and 404.348-404.349

OMB No. 0960-0019

1. Justification

1. Introduction/Authoring Laws and Regulations

Sections 202(b)(l)(B), 202 (c)(l)(B), and 202(g)(l)(E) of the Social Security Act (Act), and 20 CFR 404.330, 404.339-404.341, and 404.348-404.349 of the Code of Federal Regulations, contain the “in-care” entitlement requirement and the conditions under which a claimant meets it. A requirement for entitlement to Social Security benefits as a mother; a father; a surviving divorced mother or father; or as a spouse who is under age 62, is that the spouse under age 62; the surviving divorced mother or father; the mother; or the father must have in their care an entitled child (under age 16 or disabled) of the worker.

2. Description of Collection

SSA uses Form SSA-781 to determine if non-custodial parents who file for spouse, mother’s, father’s, or surviving divorced mother’s or father’s benefits based on having a child in their care, meet the “in-care” requirements. The in-care provision requires claimants to have an entitled child under age 16, or disabled in their care. The respondents are applicants for spouse; mother’s; father’s, or surviving divorced mother’s or father’s Social Security benefits.

3. Use of Information Technology to Collect the Information

Form SSA-781 is available for the respondent to print from SSA’s website, complete, and mail back to SSA. SSA did not create an electronic version of

Form SSA-781 under the agency’s Government Paperwork Elimination Act (GPEA) plan because only 14,000 respondents complete the form annually. This is less than the GPEA cut-off of 50,000.

4. Why We Cannot Use Duplication Information

The nature of the information we collect and the manner in which we collect it preclude 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 use Form SSA-781, we would not be able to determine whether the claimant meets the statutory “in ­care” requirement. Because we only collect the information once, we cannot collect it 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 November 9, 2018, at

83 FR 56133, and we received no public comments. The 30-day FRN published on January 25, 2019 at 84 FR 371. If we receive any comments in response to this Notice, we will forward them to OMB. SSA did not consult with the public in the revision of this form.

9. Payment or Gifts to Respondents

SSA does not provide payment or gifts to the respondents.

10. 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.

11. Justification of Sensitive Questions

The information collection does not contain any questions of a sensitive nature.

12. Estimates of Public Reporting Burdon

Modality of Completion	Number of Respondents	Frequency of Response	Average Burden Per Response (minutes)	Estimated Total Annual Burden (hours)
SSA-781	14,000	1	10	2,333

The total burden for this ICR is 2,333 hours. We based this figure on current management information data. 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 the Federal Government

The annual cost to the Federal Government is approximately $76,276. This estimate accounts for costs from the following areas: (1) designing, printing, and distributing the form; and (2) SSA employee (e.g., field office, 800 number, DDS staff) information collection and processing time.

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.

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