Supporting Statement for Form SSA-1709
Request for Workers' Compensation/Public Disability Information
20 CFR 404.408(e)
OMB # 0960-0098
A. Justification
1. Section 224 of the Social Security Act (the Act) provides for an offset of Disability Insurance Benefits (DIB) when Workers' Compensation (WC) and/or Public Disability benefit (PDB) are being received by the beneficiary. 20 CFR 404.408(e) of the Code of Federal Regulations provides that an "individual may be required ... to furnish evidence as requested by the Administration". If the worker is unable to provide evidence verifying the amount of any WC/PDB the are being paid, the Social Security Administration (SSA) must obtain such information from the Federal, State or local agency administering the WC/PDB, self-insured public or private employer, or insurance carrier.
SSA uses Form SSA-1709 as verification of WC/PDB benefits. SSA uses the information to compute the correct reduction in the DIB. The claimant may be able to furnish adequate verification of the WC/PDB benefits by submitting a copy of his or her award notice, benefit check, etc. SSA considers the claimant as the primary source of verification, and if he or she provides the necessary evidence, the form is not used. If the claimant cannot provide evidence, the only other reliable source of this information is the entity giving the benefits, its agent (such as an insurance carrier), or an administering public agency. The respondents are Federal, State, and local agencies administering WC/PDB, insurance carriers and public or private self-insured companies.
3. Form SSA- 1709 is available on SSA’s website for individuals to print, complete and mail to SSA for processing. An electronic version is not available, due to higher volume forms taking precedence.
4. The nature of the information we are collecting and the manner in which we are collecting it preclude duplication. SSA does not use another collection instrument to collect similar data.
5. This collection does not significantly affect a substantial number of small businesses or other small entities.
If SSA did not collect the information, incorrect payments could result. In addition, since SSA collects this information on an as needed basis, we cannot collect it less frequently. There are no technical or legal obstacles to burden reduction.
7. There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.
8. The 60-day advance Federal Register Notice published on March 23, 2009, at 74 FR 12170, and SSA received no public comments. The second Notice published on May 21, 2009, at 74 FR23916. SSA did not consult members of the public in the development of this form.
9. SSA provides no payment or gifts to the respondents.
10. SSA protects and holds confidential the information it is requesting 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.
11. The information collection does not contain any questions of a sensitive nature.
12. Approximately 120,000 respondents use Form SSA-1709 annually. The estimated average response time is 15 minutes, for a total of 30,000 burden hours. The total burden represents burden hours, and SSA did not calculate a separate cost burden.
13. There is no known cost burden to the respondents.
The annual cost to the Federal Government is approximately $600,000.00. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.
15. There are no changes in the public reporting burden.
16. SSA will not publish the results of the information collection.
17. OMB exempted SSA from the requirement to print the OMB approval expiration date 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 the agency would not have to discontinue using otherwise useable editions of forms with outdated expiration dates. In addition, SSA avoids Government waste, because we will not have to destroy and reprint stocks of forms.
18. 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).
B. Collections of Information Employing Statistical Methods
SSA is not using statistical methods for this collection.
| File Type | application/msword |
| File Title | November 1995 |
| Author | jtroy |
| Last Modified By | Mandley, Tasha |
| File Modified | 2009-06-10 |
| File Created | 2009-02-02 |