SSA Guidance for Use of the Tax Information Authorization Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 8821 Guidance.pdf	Supplementary Document	Uploaded 2007-01-03	Available
IRS Form 8821.pdf	Supplementary Document	Uploaded 2007-01-03	Available
Disclosure Authorization Plan.doc	Supplementary Document	Uploaded 2007-01-03	Available
IRS Agreement Letter.pdf	Supplementary Document	Uploaded 2007-01-03	Available
IRS Form 8821 Emergency Clearance Request Letter.doc	Supplementary Document	Uploaded 2007-01-03	Available
IRS Form 8821 Supporting Statement.doc	Supporting Statement A	Uploaded 2007-01-03	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
46610	SSA Guidance for Use of the Tax Information Authorization Form	Instruction	New

ICR Details

OMB Control No: 0960-0738	ICR Reference No: 200701-0960-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: SSA	Agency Tracking No:
Title: SSA Guidance for Use of the Tax Information Authorization Form
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 01/03/2007
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/04/2007
	Date Received in OIRA: 01/03/2007
Terms of Clearance: SSA should promptly start the process for a full ICR: i.e., SSA should aim to publish a 60-day FR notice within 30 days of receiving approval for this emergency clearance so that the instruction sheet has had a chance to go through the full PRA process well before the 6 months are up for this emergency clearance.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2007	6 Months From Approved
Responses	6,000	0	0
Time Burden (Hours)	1,500	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Internal Revenue Service (IRS) Form 8821 is used by taxpayers to authorize the release of tax information to a third party. The IRS agrees that a properly completed IRS Form 8821 is an appropriate means of designating the Department of Health and Human Services (HHS) to receive the tax information of a Medicare Part B beneficiary who has appealed a determination of Income-Related Monthly Adjustment Amount (IRMAA). Specifically, Medicare Part B beneficiaries who wish to appeal SSA's reconsideration of their IRMAA amounts will be sent a copy of the HA-501 (Request for Hearing by an Administrative Law Judge) and with it the IRS Form 8821, which will enable beneficiaries to authorize disclosure of their relevant beneficiary tax data to HHS for use in conducting the appeals hearing. The respondents are Medicare Part B beneficiaries who want to request an appeal of their IRMAA amount.

Emergency Justfication: Please see attached emergency request letter under "Supplementary Documents" for justification.

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Authorizing Statute(s): PL: Pub.L. 108 - 173 811 Name of Law: Medicare Modernization Act of 2003
   US Code: 26 USC 6103(a) Name of Law: null
  

Citations for New Statutory Requirements: PL: Pub.L. 108 - 173 811 Name of Law: Medicare Modernization Act of 2003

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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:
	72 FR 175	01/03/2007
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
SSA Guidance for Use of the Tax Information Authorization Form

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ICR Summary of Burden

table that charts list of burden

	Total Approved	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	6,000	0	6,000	0	0	0
Annual Time Burden (Hours)	1,500	0	1,500	0	0	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: This increase in burden is caused by SSA's new use of the existing IRS Form 8821. Medicare Part B beneficiaries will use this form to authorize SSA to release their tax data to HHS. In turn, HHS will use this data to conduct appeals hearings. See attached request for emergency clearance letter for further details.

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Annual Cost to Federal Government: $0

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

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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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: 01/03/2007

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