1530-0010_SupStmt_2021

Supporting Statement

OMB No. 1530-0010

FS 1133 Series of Claim Forms

1. Justification

1. Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collection.

The Bureau of the Fiscal Service, Payment Management (PM) requires that everyone who makes a claim of non-receipt against the United States for the Proceeds of a U.S. Treasury payment must complete a Claim Form. The forms are used to determine if a payee is entitled to the proceeds of the payment. An analysis is conducted using the answers provided on the form (produced by the claimant) to determine if fraud is involved. The claim forms contain information found in 31 United States Code, Section 321 and 3331-3343, as to the authority of the Treasury Department to consider a claim.

2. Indicate how, by whom, and for what purpose the information is to be used.

Information presented to PM by the claimant on the FS Form 1133 Series of Claim Forms is required in order to process the individual claim for a payment obligation owed. A Senior Teletrace Specialist can make a determination of fraud and then complete the necessary steps to settle the claim, or notify the program agency that the settlement of the claim is recommended. If the collection and analysis of the information provided on the claim form was not conducted, PM would have no basis with which to adjudicate the payee’s claim for the proceeds of the check. FS Form 1133A is used for claims filed with the Social Security Administration (SSA) and FS Form 1133 is used for all other claims.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology. What consideration is given to use information technology to reduce burden?

The Claim Forms are available from the Bureau of the Fiscal Service and also on the Internet as a PDF form. No information systems or technologies have been developed and/or employed to reduce the reporting burden.

4. Describe efforts to identify duplication. Why can’t any similar information already available be used or modified for use for the purposes described in item 2 above?

Similar data is not available from other agencies, or any other sources.

5. If the collection of information impacts small business or other small entities describe any methods used to minimize burden?

This collection of information does not impact small business or other small entities.

6. What consequences to Federal program or policy activities and what, if any, technical or legal obstacles to reducing burden will occur if this collection is not conducted or is conducted less frequently?

The collection of information does not occur on a constant or fixed basis. It is only generated as an aftermath of a payee claiming entitlement to the proceeds of a U.S. Treasury payment which he/she alleges not to have received. If the confirmation is not collected from the claimant, the claim of non-receipt and/or fraud cannot be substantiated.

7. Is this collection of information conducted in a manner consistent with the guidelines of 5 CFR 1320.6?

There are no special circumstances that require the collection of data to be conducted in a manner consistent with the guidelines set forth in 5 CFR 1320.6.

8. What effort was made to notify the general public about this collection of information?

The Bureau’s notice was published in Volume 86 of the Federal Register on June 30, 2021 page 34843. No comments were received.

9. What decision was made to provide any payment or gift to respondents, other than reenumeration of contractors or grantees?

There are no offers of payments or gifts to respondents for the collection of this information.

10. What assurance of confidentiality was provided to respondents and what was the basis for the assurance in statute, regulations, or agency policy?

Aside from protections contained in the Privacy Act, there is no guarantee of confidentiality.

11. What justification is there for questions of a sensitive nature?

A minimal amount of Personally Identifiable Information (PII) in this collection is necessary in order to properly adjudicate the claim. The information is addressed within Treasury/Fiscal Service .002 Payment Records and appears in the System of Records Notice published in the Federal Register on February 27, 2020.

The Privacy Impact Assessment (PIA) that covers Payment Automation Manager (PAM) is available at https://www.fiscal.treasury.gov/files/pia/pampclia.pdf

The Bureau of the Fiscal Service conducts a PIA on information systems collecting personally identifiable information from the public. We do PIAs to ensure that:

• we tell the public the information that we collect about them,

• we adequately address impacts these systems have on personal privacy,

• we collect only enough personal information to administer our programs, and no more.

Also, PIAs confirm that we use the information for the purpose intended; that the information remains timely and accurate; that it is protected while we have it, and we hold it only for as long as we need it.

12. What is the estimated hour burden of this collection of information?

Estimates of the burden of collection are as follows:

Form	No. of Respondents	No. of Responses Per Respondent	No. of Annual Responses	Hours Per Response	Total Annual Burden
FS FORM 1133	27,640	1	27,640	0.17	4,608
FS FORM 1133A	24,000	1	24,000	0.17	4,001
TOTALS	51,640		51,640	0.17	8,609

13. What is the estimated total annual cost burden to respondents or recordkeepers resulting from this collection of information?

There are no capital/start-up or ongoing operation/maintenance costs associated with this information collection.

14. What is the annualized cost to the Federal Government?

Estimates of annualized costs to the Federal Government (costs associated with the design, processing, mailing, collecting data and printing of the form) is $377,500.

15. What is the reason for any program changes or adjustments reported in Items 13 or 14 of the OMB Form 83-I?

No changes or adjustments are reported.

16. For collections of information whose results will be published, outline plans for tabulation and publication.

There are no plans to externally publish the results of the collection information.

17. If seeking approval to not display the expiration date for OMB approval of this information collection, what are the reasons that the display would be inappropriate?

The Bureau of the Fiscal Service requests the non-display of the expiration date of the OMB approval. The display of this date may cause confusion to users by implying that actions must be taken by a prescribed date. Also, printed versions may carry outdated information that may be misinterpreted.

18. What are the exceptions to the certification statement?

There are no exceptions to the certification statement.

2. Collection of Information Employing Statistical Methods

The collection of information does not employ statistical methods.

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