Supporting Statement 0534

Supporting Statement for Form SSA-773-U4

Waiver of Right to Appear – Disability Hearing

20 CFR 404.913-.914, 404.916(b)(5), 416.1413-.1414, 416.1416(b)(5)

OMB No. 0960-0534

A. Justification

1. Introduction/Authoring Laws and Regulations - Section 205(b) of the Social Security Act (the Act) and 20 CFR 404.913-.914 and 416.1413-.1414 of the Code of Federal Regulations provide an evidentiary hearing at the reconsideration level of appeal for claimants who have received an initial or revised determination that a disability did not exist or has ceased. 20 CFR 404.916(b)(5) and 416.1416(b)(5) state that, “You may waive your right to appear at the hearing. If you do not appear at the hearing, the disability hearing officer will prepare and issue a written reconsidered determination based on the information in your file.”

2. Description of Collection - SSA uses Form SSA-773-U4 for claimants or their representatives to officially waive their right to appear at a disability hearing. The disability hearing officer uses the signed form as a basis for not holding a hearing and for preparing a written decision based solely on the evidence of record. The respondents are claimants for disability under Title II and Title XVI of the Act, or their representatives, who officially waive their right to appear at a disability hearing.

3. Use of Information Technology to Collect Information - The SSA-733-U4 is available through the Internet in a portable document format (PDF) for the public to download, print, fill out, and send to SSA for processing. Paper copies of the form are also available to claimants. The respondent must mail a copy of the form to SSA. SSA does not have an electronic version of Form SSA-773-U4 nor have we scheduled this information collection for electronic implementation due to its relatively low volume of use.

4. Why We Cannot Use Duplicate Information - The nature of the information SSA is collecting and the manner in which we are collecting it preclude duplication. SSA uses no other collection instrument to obtain similar data.

5. Minimizing Burden on Small Respondents - This collection does not affect small businesses or other small entities.

6. Consequence of Not Collecting Information or Collecting it Less Frequently - This information collection occurs when a claimant files a waiver of his/her right to appear at a disability hearing. If SSA did not collect this information, claimants would not have a structured format in which to request a waiver to appear for a hearing nor documentation informing them of the effects of their decision to waive that right. Further, SSA would lack documentation of the claimants informed decision. Since SSA requests this information on an as needed basis, we cannot collect it less frequently. There are no technical or legal obstacles that prevent burden reduction.

7. Special Circumstances -There are no special circumstances that would cause SSA to collect this information in a manner that is not consistent with 5 CFR 1320.5.

8. Solicitation of Public Comment and Other Consultations with the Public - SSA published the 60-day advance Federal Register Notice on July 27, 2009 at 74 FR 37081, and we received no public comments. We published the 30-day Federal Register Notice on September 24, 2009 at 74 FR 48795. There have been no outside consultations with members of the public.

9. Payment of Gifts to Respondents - SSA provides no payment or gifts to the respondents.

10. Assurances of Confidentiality - SSA protects and holds confidential the information from this collection 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. Justification for Sensitive Questions - The information collection does not contain any questions of a sensitive nature.

12. Estimates of Public Reporting Burden - We estimate that 200 claimants will waive their right to appear at a disability hearing. The estimated average response time is 3 minutes per request, for a total of 10 burden hours annually. The total burden reflects burden hours, and we did not calculate a separate cost burden.

13. Annual Cost to the Respondents - There is no known cost burden to the respondents.

14. Annual Cost to the Federal Government - The annual cost to the Federal government is $308. This estimate is for printing and distributing the collection instrument and for collecting the information.

15. Program Changes or Adjustments to the Information Collection Request - There are no changes in the public reporting burden.

16. Plans for Publication Information Collection Results - SSA will not publish the results of the information collection.

17. Displaying the OMB Approval Expiration Date - OMB granted SSA an exemption from the requirements to print the OMB expiration date on its program forms. SSA produces millions of public-use forms with life cycles exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis), OMB granted this exemption so SSA would not have to destroy stocks of otherwise useable forms with expired OMB approval dates, avoiding Government waste.

18. Exception to Certification Statement - 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).

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B. Collections of Information Employing Statistical Methods

SSA did not use statistical methods for this information collection.