Request for Reinstatement (Title II)

Forms and Documents

Document Name	Status
Form SSA-371 Request for Reinstatement (Title II) Form	Modified
Supporting Statement 0742 revised.doc Supporting Statement A	2009-12-08
addendum-0742.doc Supplementary Document	2009-11-27

IC Document Collections

IC ID	Document Title	Status
45431	Request for Reinstatement (Title II) Form	Modified

ICR Details

OMB Control No: 0960-0742	ICR Reference No: 200909-0960-007
Status: Historical Active	Previous ICR Reference No: 200609-0960-028
Agency/Subagency: SSA	Agency Tracking No:
Title: Request for Reinstatement (Title II)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/11/2010
	Date Received in OIRA: 12/09/2009
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2013	36 Months From Approved	05/31/2010
Responses	10,000	0	10,000
Time Burden (Hours)	333	0	333
Cost Burden (Dollars)	0	0	0

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Abstract: Through Form SSA–371, SSA obtains a signed statement from individuals stating a request for Expedited Reinstatement (EXR) of their Title II disability benefits, and proof the requestor meets the EXR requirements. SSA maintains the form in the disability folder of the applicant to demonstrate the individual’s awareness of the EXR requirements and their choice to request EXR. Respondents are individuals requesting expedited reinstatement of his or her Title II disability benefits.

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Authorizing Statute(s): US Code: 42 USC 423 Name of Law: Social Security Act
   PL: Pub.L. 106 - 170 112 Name of Law: Ticket to Work and Work Incentives Improvement Act of 1999
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 51353	10/06/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 64801	12/08/2009
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Request for Reinstatement (Title II)	SSA-371	Request for Reinstatement - Title II

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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	10,000	10,000	0	0	0	0
Annual Time Burden (Hours)	333	333	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $46,200

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)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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: 12/09/2009

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