Supporting Statement for Form SSA-L4163
Agency/Employer Government Pension Offset Questionnaire
20 CFR 404.408(a)
OMB No. 0960-0470
A. Justification
Introduction/Authoring Law and Regulations
Section 202(k)(5) of the Social Security Act (Act), as codified in
20 CFR 404.408(a) of the Code of Federal Regulations, mandates the Social Security Administration (SSA) to reduce a spouse’s or surviving spouse’s Social Security benefits when the spouse also receives a government pension based on employment not covered by Social Security. SSA may reduce the benefit by
two-thirds of the amount of the non-covered government pension under the Act’s Government Pension Offset (GPO) provision. SSA uses Form SSA‑L4163, Agency/Employer Government Pension Offset Questionnaire, to document such cases.
Description of Collection
When an individual is concurrently receiving Social Security spousal, or surviving spousal, benefits and a government pension, the individual may have the amount of Social Security benefits reduced by the government pension amount. This is the Government Pension Offset (GPO). SSA uses Form SSA-L4163 to collect accurate pension information from the Federal or State government agency paying the pension for purposes of applying the pension offset provision. SSA uses this form only when (1) the claimant does not have the information; and (2) the pension-paying agency has not cooperated with the claimant. Respondents are State government agencies, which have information SSA needs to determine if the GPO applies, and, if so, the amount of offset.
Use of Information Technology to Collect the Information
SSA did not create an electronic version of form SSA-L4163 under the agency’s Government Paperwork Elimination Act (GPEA) plan because only 2,911 respondents complete the form annually. This is less than the GPEA cut-off of 50,000.
Why We Cannot Use Duplicate 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.
Minimizing Burden on Small Respondents
This collection does not significantly affect small businesses or other small entities.
Consequence of Not Collecting Information or Collecting it Less Frequently
If we did not use the SSA-L4163, SSA would be unable to determine the GPO and pay the correct Social Security benefit for claimants who are unable to provide the agency with the necessary requested information. This could result in an overpayment or underpayment of Social Security benefits to the claimant. Because we collect the information on an as needed basis, we cannot collect the information less frequently. There are no technical or legal obstacles to burden reduction.
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.
Solicitation of Public Comment and Other Consultations with the Public
The 60-day advance Federal Register Notice published on May 22, 2019, at
84 FR 23623, and we received no public comments. The 30-day FRN published on August 1, 2019 at 84 FR 37704. If we receive any comments in response to this Notice, we will forward them to OMB.
Payment of Gifts to Respondents
SSA does not provide payments or gifts to the respondents.
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.
Justification for Sensitive Questions
This information collection does not contain any questions of a sensitive nature.
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-L4163 |
2,911 |
1 |
3 |
146 |
The total burden for this ICR is 146 hours. We based these figures on current management information data. This figure represents burden hours, and we did not calculate a separate cost burden.
Annual Cost to the Respondents
This collection does not impose a known cost burden on the respondents.
Annual Cost to the Federal Government
The annual cost to the Federal Government is approximately $3,539. 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.
Program Changes or Adjustments to the Information Collection Request
When we last cleared this IC in 2016, the burden was 50 hours. However, we are currently reporting a burden of 145 hours. This change stems from an increase in the number of responses from 50 to 145. There is no change to the burden time per response. Although the number of responses changed, SSA did not take any actions to cause this change.
Plans for Publication Information Collection Results
SSA will not publish the results of the information collection.
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 usable forms with expired OMB approval dates, avoiding Government waste.
Exemption to Certification Statement
SSA is not requesting an exception to the certification requirements at
5 CFR 1320.9 and related provisions at 5 CFR 1320.9(b)(3).
B. Collections of Information Employing Statistical Methods
SSA does not use statistical methods for this information collection.
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