Social Security Benefits Application

Forms and Documents

Document	Type	Status	Availability
Form SSA-1 Medicare-only Paper Form SSA-1	Form and Instruction	New	Repair queued
Form SSA-16 Paper Form SSA-16 (Application for Disability Insurance Benefits )	Form and Instruction	Unchanged	Repair queued
Form SSA-2 Paper Form SSA-2 (Application for Wife's or Husband's Insurance Benefits)	Form and Instruction	Unchanged	Repair queued
Form SSA-1 Paper Form SSA-1 (Application for Retirement Insurance Benefits)	Form	Modified	Available
0960-0618 addendum (2009).doc	Supplementary Document	Uploaded 2009-11-24	Available
0960-0618 (Medicare-only iClaim) supporting statement.DOC	Supporting Statement A	Uploaded 2009-11-20	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
9628	1st Party Internet Social Security Benefits Application (iClaim)	Other-iClaim Screens - 1st party respondents	Modified
191246	Medicare-only iClaim (new part of ICR)	Other-Internet screens	New
191245	Medicare-only Paper Form SSA-1	Form and Instruction	New
191244	Medicare-only MCS screens	Other-MCS screens for Medicare-only (will be modified in intervi	New
188103	February 2009 Survey of Title II Disability Applicants	Other-Brief follow-up survey	Removed
184984	Notices to Beneficiaries who Have Third Parties Applying for them Via iClaim	Other-Notices to Beneficiaries with 3rd-party iClaim completion	Modified
184982	3rd Party iClaim	Other-iClaim screens -- for 3rd parties	Modified
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	Modified
179338	SSA-1 MCS Signature Proxy	Other-MCS/Signature Proxy	Modified
179334	SSA-1 MCS Screens	Other-MCS Screens	Unchanged

ICR Details

OMB Control No: 0960-0618	ICR Reference No: 200911-0960-003
Status: Historical Active	Previous ICR Reference No: 200902-0960-016
Agency/Subagency: SSA	Agency Tracking No:
Title: Social Security Benefits Application
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: 01/29/2010
	Date Received in OIRA: 11/24/2009
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2013	36 Months From Approved	08/31/2011
Responses	5,124,218	0	5,009,218
Time Burden (Hours)	1,248,556	0	1,231,656
Cost Burden (Dollars)	0	0	0

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Abstract: This collection includes the various modalities for benefits applications, including forms SSA-1, SSA-2, SSA-16 (and the corresponding MCS/in-person interview systems), and the online iClaim system. In this Information Collection Request, we will be clearing the new Medicare-only iClaim application.

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Authorizing Statute(s): US Code: 42 USC 402 Name of Law: Social Security Act
   US Code: 42 USC 423 Name of Law: Social Security Act
   US Code: 42 USC 426 Name of Law: Social Security Act
   US Code: 42 USC 1395j Name of Law: Social Security Act
   US Code: 42 USC 1395o Name of Law: Social Security Act
  

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 18782	04/24/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 59336	11/17/2009
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 15

IC Title	Form No.	Form Name
SSA-1 MCS Screens
SSA-1 MCS Signature Proxy
SSA-16 MCS Signature Proxy
SSA-2 MCS Screens
3rd Party iClaim
Medicare-only MCS screens
Medicare-only Paper Form SSA-1	SSA-1	Application for Retirement Insurance Benefits
Medicare-only iClaim (new part of ICR)
February 2009 Survey of Title II Disability Applicants
Notices to Beneficiaries who Have Third Parties Applying for them Via iClaim
1st Party Internet Social Security Benefits Application (iClaim)
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

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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	5,124,218	5,009,218	0	115,000	0	0
Annual Time Burden (Hours)	1,248,556	1,231,656	0	31,916	-15,016	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The burden increase was due to the addition of the Medicare-only iClaim application, whose response time is slightly longer than paper Medicare-only applications (although the iClaim version is more convenient). There is no actual burden reduction, but ROCIS registers one because we reduced the total SSA-1 paper and MCS ICs number of respondents, as we now have separate ICs for the Medicare-only subsets of those forms.

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Annual Cost to Federal Government: $6,425,839

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: 11/24/2009

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