Supporting Statement--0045

Supporting Statement

Form SSA–795, Statement of Claimant or Other Person

20 CFR 404.702, 20 CFR 416.570

OMB No. 0960-0045

1. Justification

1. Section 205(a) of the Social Security Act requires the Commissioner to “… regulate and provide for the nature and extent of the proofs and evidence and the methods of taking and furnishing the same in order to establish the right to benefits.” Interested parties use Form SSA-795 to make signed statements relating to claims for Social Security or Supplemental Security Income, under 20 CFR 404.702 and 416.570 of the Code of Federal Regulations. For example, 20 CFR 416.570 indicates a signed statement is necessary before recovery of any overpayment by adjustment of any overpayment under Title II, Title VIII, or Title XVIII. A recipient of any of these programs may elect to have an overpayment withheld from benefits and use the SSA‑795 for this purpose.

2. Recipients also use Form SSA-795 in special situations where there is no authorized form or questionnaire. SSA uses it to obtain information from claimants or other persons having knowledge of facts in connection with claims for Social Security or Supplemental Security Income. The information requested on this form must be of sufficient importance that a signed statement, including a penalty clause, is necessary. SSA uses this information to process, in addition to claims for benefits, issues about continuing eligibility, ongoing benefit amount, use of funds by a representative payee, fraud investigation, and a myriad of other program-related matters. The most typical respondents are applicants for Social Security or Supplemental Security Income or recipients of these programs. However, respondents could also include friends and relatives of the involved parties, coworkers, neighbors, or anyone else in a position to provide information pertinent to the issue(s).

3. This agency-initiated form is simply a blank space followed by the penalty clause, allowing the person signing the form to provide any information desired. SSA also created a remarks screen in MSSICS to collect this information electronically via telephone or personal interview. As the electronic version is a blank MSSICS screen, and most respondents use the paper SSA-795, SSA does not currently track the percentage of users for the screen. In addition, since the collection of this information is agency-initiated, and because this form contains only a blank space and no formal questions, SSA has not made this form available electronically through an Internet application.

4. The nature of the information requested and the manner in which it is collected preclude duplication.

4. The collection of information does not involve small businesses or other small entities.

4. SSA uses no other form to collect data similar to that collected on form SSA-795. Using the SSA-795, SSA collects information on unresolved issues from claimants or other persons when as needed to adjudicate claims or to resolve post-entitlement issues. If SSA did not collect this information, we could not properly adjudicate claims for benefits or resolve post-entitlement issues. Since SSA only collects the information on an as-needed basis, we could not collect it less frequently.

4. There are no special circumstances that would cause SSA to conduct this information collection in a manner that is not consistent with 5 CFR 1320.5.

4. The 60-day advance Federal Register Notice published on April 7, 2009, at 74 FR 15808, and SSA has received no public comments. The second Notice published on July 10, 2009 at 74 FR 33313. There have been no outside consultations with members of the public.

4. SSA provides no payment or gifts to the respondents.

10. The information provided on this form is protected and held confidential in accordance with 42 U.S.C.,1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974) and OMB Circular No. A-130.

10. The information collection does not contain any questions of a sensitive nature.

10. Approximately 305,500 respondents use Form SSA-795 annually. The estimated average completion time is 15 minutes per form for a total annual burden of 76,375 hours. The total burden reflects as burden hours, and SSA has calculated no separate cost burden.

10. There is no known cost burden to the respondents.

10. The annual cost to the Federal Government is approximately $470,470. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.

10. There are no changes in the public reporting burden.

10. SSA will not publish the results of the information collection.

10. OMB has granted SSA an exemption from the requirement to print the expiration date for OMB approval on its program forms. SSA produces millions of public-use forms, many of which have a life cycle longer than that of an OMB approval. SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis). OMB granted this exemption so that SSA would not need to take otherwise useable editions of forms out of circulation because the expiration date had been reached. In addition, SSA avoids Government waste because we will not need to destroy or reprint stocks of forms.

10. SSA is not requesting an exception to the certification requirements at 5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b)(3).

2. Collection of Information Employing Statistical Methods

SSA is not using statistical methods for this information collection.