SSA-8000-BK - 20 CFR, 416.207 & Subpart C, 416.305-.335

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-8000-BK Application for Supplemental Security Income	Form	Modified	Available
Explanation Change Worksheet.doc	Justification for No Material/Nonsubstantive Change	Uploaded 2007-06-07	Available
Signature Proxy 83c Justifications 07-17-06-- FINAL[1].doc	Justification for No Material/Nonsubstantive Change	Uploaded 2006-08-31	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9158	Application for Supplemental Security Income / MISSICS		Unchanged
44924	SSA-8000-BK - Application for Supplemental Security Income	Form	Modified	Application for Supplemental Security Income
44923	Application for Supplemental Security Income MISSICS / Signature Proxy		Unchanged

ICR Details

OMB Control No: 0960-0229	ICR Reference No: 200705-0960-014
Status: Historical Active	Previous ICR Reference No: 200608-0960-015
Agency/Subagency: SSA	Agency Tracking No:
Title: SSA-8000-BK - 20 CFR, 416.207 & Subpart C, 416.305-.335
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/21/2007
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/07/2007
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2008	06/30/2008	06/30/2008
Responses	1,128,374	0	1,128,374
Time Burden (Hours)	675,285	0	675,285
Cost Burden (Dollars)	0	0	0

---

Abstract: The information collected using Form SSA-8000-BK is needed and used to determine eligibility for Supplemental Security Income (SSI) and the amount of benefits payable. The respondents are applicants for SSI payments.

---

Authorizing Statute(s): US Code: 42 USC 1383
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

IC Title	Form No.	Form Name
Application for Supplemental Security Income / MISSICS
Application for Supplemental Security Income MISSICS / Signature Proxy
SSA-8000-BK - Application for Supplemental Security Income	SSA-8000-BK	Application for Supplemental Security Income

---

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	1,128,374	1,128,374	0	0	0	0
Annual Time Burden (Hours)	675,285	675,285	0	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: The Application for Supplement Security Income is one of the collections cited under our ICB burden reduction Initiative Signature Proxy. The Signature Proxy Initiative is an alternative to the traditional pen and ink or “wet” signature, and it eliminates the need to retain paper applications in most circumstances by allowing the technician to process the application on the claimant’s behalf, without a signature. In most instances, Signature Proxy allows SSA to store and process the entire benefit application electronically, thus reducing costs associated with mailing and storing physical files. In addition, the adoption of Signature Proxy supports faster processing of claims and will improve service to the public by eliminating the need to mail the application to the claimant and wait for it to be signed and returned. Please see the attached Supplementary Documentation which outlines the burden savings achieved through this collection and all other applications in the Signature Proxy Initiative.

---

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

---

Common Form ICR:  No

---

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: 06/07/2007

---