Social Security Benefits Application

Forms and Documents

Document Name	Status
Form SSA-16 Paper Form SSA-16 (Application for Disability Insurance Benefits ) Form and Instruction	Unchanged
Form SSA-2 Paper Form SSA-2 (Application for Wife's or Husband's Insurance Benefits) Form and Instruction	Unchanged
Form SSA-1 Paper Form SSA-1 (Application for Retirement Insurance Benefits) Form	Unchanged
0960-0618 2009 Title II survey questions.doc Supplementary Document	2009-02-19
0960-0618 non-substantive change (brief survey).doc Justification for No Material/Nonsubstantive Change	2009-02-19

IC Document Collections

IC ID	Document Title	Status
9628	1st Party Internet Social Security Benefits Application (ISBA) Other-ISBA Screens - 1st party respondents	Unchanged
188103	February 2009 Survey of Title II Disability Applicants Other-Brief follow-up survey	New
184984	Notices to Beneficiaries who Have Third Parties Applying for them Via ISBA Other-Notices to Beneficiaries with 3rd-party IBSA completion	Unchanged
184982	3rd Party Internet Social Security Benefits Application (ISBA) Other-ISBA screens -- for 3rd parties	Unchanged
179349	Paper Form SSA-16 (Application for Disability Insurance Benefits ) Form and Instruction	Unchanged
179348	SSA-16 MCS Signature Proxy Other-MCS/Signature Proxy	Unchanged
179347	SSA-16 MCS Screens Other-MCS Screens	Unchanged
179344	Paper Form SSA-2 (Application for Wife's or Husband's Insurance Benefits) Form and Instruction	Unchanged
179343	SSA-2 MCS Signature Proxy Other-MCS Signature Proxy Screens	Unchanged
179341	SSA-2 MCS Screens Other-MCS Screens	Unchanged
179340	Paper Form SSA-1 (Application for Retirement Insurance Benefits) Form	Unchanged
179338	SSA-1 MCS Signature Proxy Other-MCS/Signature Proxy	Unchanged
179334	SSA-1 MCS Screens Other-MCS Screens	Unchanged

ICR Details

OMB Control No: 0960-0618	ICR Reference No: 200902-0960-016
Status: Historical Active	Previous ICR Reference No: 200812-0960-004
Agency/Subagency: SSA	Agency Tracking No:
Title: Social Security Benefits Application
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: 03/12/2009
	Date Received in OIRA: 02/19/2009
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2011	08/31/2011	08/31/2011
Responses	5,009,218	0	4,924,218
Time Burden (Hours)	1,231,656	0	1,230,239
Cost Burden (Dollars)	0	0	0

---

Abstract: As per our discussion with OMB in previous weeks, we are conducting a brief (two-question) telephone survey with Title II disability applicants. Explanation and survey questions are attached.

---

Authorizing Statute(s): US Code: 42 USC 423 Name of Law: Social Security Act
   US Code: 42 USC 402 Name of Law: Social Security Act
  

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
60-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 15252	03/21/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 29833	05/22/2008
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 13

IC Title	Form No.	Form Name
3rd Party Internet Social Security Benefits Application (ISBA)
February 2009 Survey of Title II Disability Applicants
Notices to Beneficiaries who Have Third Parties Applying for them Via ISBA
1st Party Internet Social Security Benefits Application (ISBA)
SSA-2 MCS Signature Proxy
Paper Form SSA-2 (Application for Wife's or Husband's Insurance Benefits)	SSA-2	Application for Wife's or Husband's Insurance Benefits
Paper Form SSA-16 (Application for Disability Insurance Benefits )	SSA-16	Application for Disability Insurance Benefits
Paper Form SSA-1 (Application for Retirement Insurance Benefits)	SSA-1	Application for Retirement Insurance Benefits
SSA-16 MCS Screens
SSA-1 MCS Screens
SSA-1 MCS Signature Proxy
SSA-16 MCS Signature Proxy
SSA-2 MCS Screens

---

ICR Summary 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	5,009,218	4,924,218	0	85,000	0	0
Annual Time Burden (Hours)	1,231,656	1,230,239	0	1,417	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Temporary burden increase due to the brief two-week survey SSA is conducting. After the survey is complete, we will return the burden to its previous levels.

---

Annual Cost to Federal Government: $3,372,000

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: 02/19/2009

---