Important Information About Your Appeal, Waiver Rights and Repayment Options

Forms and Documents

Document Name	Status
Form SSA-3105 Important Information About Your Appeal, Waiver Rights, and Repayment Options - Paper Form Form and Instruction	Modified
Supporting Statement - 0779 (Final).docx Supporting Statement A	2022-01-13
Addendum - 0779 (Final).docx Supplementary Document	2022-01-12

IC Document Collections

IC ID	Document Title	Status
191893	Important Information About Your Appeal, Waiver Rights, and Repayment Options - Paper Form Form and Instruction	Modified
191691	Important Information About Your Appeal, Waiver Rights and Repayment Options - Debt Management System Other-Intranet Screens (phone call)	Modified

ICR Details

OMB Control No: 0960-0779	ICR Reference No: 202108-0960-002
Status: Received in OIRA	Previous ICR Reference No: 201807-0960-017
Agency/Subagency: SSA	Agency Tracking No:
Title: Important Information About Your Appeal, Waiver Rights and Repayment Options
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 01/13/2022

	Requested	Previously Approved
Expiration Date	36 Months From Approved	02/28/2022
Responses	666,666	700,000
Time Burden (Hours)	500,000	175,000
Cost Burden (Dollars)	0	0

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Abstract: This collection is a voluntary, one-time collection, for the respondents to let SSA know that they want to request a lower rate of benefit withholding, installment payments, an explanation of the overpayment, an appeal, or a waiver. Respondents can complete the form and return it to an SSA office, or they may also contact SSA via telephone or via an in-office visit. The respondent is not required to complete this form; however, they may complete this form alone or with help. The respondents are individuals who are overpaid Social Security payments.

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Authorizing Statute(s): US Code: 42 USC 404 Name of Law: Social Security
  

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:
	86 FR 56746	10/12/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 139	01/03/2022
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Important Information About Your Appeal, Waiver Rights and Repayment Options - Debt Management System
Important Information About Your Appeal, Waiver Rights, and Repayment Options - Paper Form	SSA-3105	Important Information About Your Appeal, Waiver Rights, and Repayment Options

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ICR Summary of Burden

	Total Request	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	666,666	700,000	0	0	-33,334	0
Annual Time Burden (Hours)	500,000	175,000	0	0	325,000	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: When we last cleared this IC in 2019, the burden was 175,000 hours. However, we are currently reporting a burden of 166,667 hours. This change stems from a decrease in the number of responses from 700,000 to 666,666. Although the number of responses changed, SSA did not take any actions to cause this change. These figures represent current Management Information data. In addition, as per OMB’s request, SSA is including the 30-minute travel time to a field office in our burden calculations, which increases the overall burden for this collection.

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Annual Cost to Federal Government: $4,671,096

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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? No

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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: 01/13/2022

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