Application for Supplemental Security Income

Forms and Documents

Document Name	Status
Form SSA-8001-BK(revise Application for Supplemental Security Income Form	Modified
Addendum - 0444 (Final).docx Supplementary Document	2022-06-07
Supporting Statement - 0444 (Final).docx Supporting Statement A	2022-06-07

IC Document Collections

IC ID	Document Title	Status
224688	iClaim/SSI Claims System Other-SSI Claims System Screen	Modified
188727	Application for Supplemental Security Income Form	Modified
188726	Application for Supplemental Security Income - SSI Claims System Other-SSI Claims System Screens	Modified

ICR Details

OMB Control No: 0960-0444	ICR Reference No: 202203-0960-008
Status: Received in OIRA	Previous ICR Reference No: 201908-0960-005
Agency/Subagency: SSA	Agency Tracking No:
Title: Application for Supplemental Security Income
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 06/07/2022

	Requested	Previously Approved
Expiration Date	36 Months From Approved	06/30/2022
Responses	962,475	973,617
Time Burden (Hours)	1,138,929	324,539
Cost Burden (Dollars)	0	0

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Abstract: SSA uses Form SSA-8001-BK to determine an applicant’s eligibility for SSI and SSI payment amounts. SSA employees also collect this information during interviews with members of the public who wish to file for SSI. SSA uses the information for two purposes: (1) to formally deny SSI for nonmedical reasons when information the applicant provides results in ineligibility; or (2) to establish a disability claim, but defer the complete development of non-medical issues until SSA approves the disability. The respondents are applicants for SSI payments.

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Authorizing Statute(s): US Code: 42 USC 1383 Name of Law: Social Security Act
  

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:
	87 FR 18456	03/30/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 33282	06/01/2022
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Application for Supplemental Security Income	SSA-8001-BK(revised)	Application For Supplemental Security Income
Application for Supplemental Security Income - SSI Claims System
iClaim/SSI Claims System

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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	962,475	973,617	0	0	-11,142	0
Annual Time Burden (Hours)	1,138,929	324,539	0	0	814,390	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 324,539 hours. However, we are currently reporting a burden of 320,825 hours. This change stems a decrease in the number of responses from 973,617 to 962,475. 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. These figures represent current Management Information data. *Note: The total burden reflected in ROCIS is 1,138,929, while the burden cited in #12 of the Supporting Statement is 320,825. This discrepancy is because the ROCIS burden reflects the following components: field office waiting time + telephone call system wait times + a rough estimate of a 30-minute, one-way, drive burden. In contrast, the chart in #12 above reflects actual burden.

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Annual Cost to Federal Government: $10,364,303

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: 06/07/2022

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