Supporting Statement SSA-4111

March 29, 2007

Supporting Statement for Form SSA-4111

Certificate of Election for Reduced Widow(er)’s Benefits

20 CFR, Subpart D, 404.335

OMB No. 0960-NEW

1. Justification

1. Reduced benefits are not payable to an already entitled spouse (or divorced spouse) who:

• is at least age 62 and under full retirement age in the month of the number holder’s death; and

• is receiving both reduced spouse’s (or divorced spouse’s) benefits and either retirement or disability benefits in the month before the month of the number holder’s death.

To request reduce benefits form SSA-4111 must be filed in accordance with Sections 202(e)(1)(C)(ii)(III), 202(f)(1)(C)(ii)(III) of the Social Security Act (the Act) and 20 CFR 404.335. Section 202(q) of the Act provides for the authority to reduce benefits.

2. The Social Security Administration (SSA) uses the information collected on Form SSA-4111 to pay a qualified dually entitled widow(er) (or surviving divorced spouse) who elects to receive a reduced widow(er) benefit.

3. Currently no other system collects this information; although this information is subsequently transcribed to electronic systems (e.g., MACADE). The electronic submission of application/form data is an Agency goal as an alternative means of doing business with SSA, unless face to face contact with the individual is required as part of the intake process or the circumstances are so sensitive or complex that the completer would be better served interacting with a trained SSA employee. That being said, electronic intake can only occur if there is functional equivalency on the backend to receive and process the electronic submission. This expenditure of Systems resources must compete with other priority initiatives over very limited funds. The SSA-4111 cannot compete with the legislative mandates that are driving the use of these funds and, therefore, this collection is currently excluded from the Government Paperwork Elimination Act.

4. The nature of the information being requested and the manner in which it is collected preclude duplication. There is no other form used by SSA that collects a dually entitled widow(er)’s (or surviving divorced spouse’s) election to receive reduced widow(er)’s benefits.

5. This collection does not impact small businesses or other small entities.

6. The consequences of not collecting this information would be that dually entitled widow(er) s that are otherwise qualified could not be paid reduced widow(er) benefits. Therefore, Form SSA-4111 cannot be used less frequently. There are no technical or legal obstacles that prevent burden reduction.

7. There is no special circumstance that would cause this information collection to be conducted in a manner that is not consistent with 5 CFR 1320.5.

8. The first Federal Register notice was published on May 21, 2007 at 72 FR 28540. The second notice was published on July 24, 2007 at 72 FR 40353. We received no public comments concerning these notices. There have been no outside consultants with members of the public.

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

10. The information requested 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.

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

12. Form SSA-4111 will be used by approximately 30,000 respondents annually. The estimated average response time is 2 minutes, for a total of 1,000 burden hours. The total burden is reflected as burden hours, and no separate cost burden has been calculated.

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

14. The annual cost to the Federal Government is approximately $46,200. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.

15. There is no change in the public reporting burden.

16. The results of the information collection will not be published.

17. OMB has granted SSA an exemption from the requirement that the expiration date for OMB approval be printed 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). This exception was granted so that otherwise useable editions of forms would not be taken out of circulation because the expiration date had been reached. In addition, Government waste has been avoided because stocks of forms will not have to be destroyed and reprinted.

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).

2. Collections of Information Employing Statistical Methods

Statistical methods are not used for this information collection.

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