Supporting Statement for OMB Clearance for SSA-104
Claimant Travel Reimbursement Request
20 CFR 404.999a- 404.999d
A. Justification
Introduction/Authoring Laws and Regulations
20 CFR 404.999a, 404.999b, 404.99c and 404.999d of the Code of Federal Regulations state that claimants applying for Title II disability benefits have the right to reimbursement for their travel expenses to and from a consultative examination (CE). In order to receive reimbursement for the travel expenses, the claimant must submit an itemized list of what he or she spent to travel round trip to the CE.
Description of Collection
SSA sends Form SSA-104 to Social Security benefits recipients with a CE appointment notice. To receive reimbursement for their travel expenses to the CE, recipients must: (1) submit an itemized list of expenditures for their round trip; and (2) complete, sign, and return the SSA-104 to SSA. SSA collects this information to determine the amount of reimbursement. Respondents are applicants for disability claims applying for reimbursement of travel expenses to a CE.
Respondents do not have to supply the same information twice (once to state agencies and then again to SSA). Rather, at the point in time that this information is being collected, it is either collected by the State Disability Determination Services (because they are processing the case) or it is collected by SSA (because we are processing the case), not by both. This collection is voluntary for respondents.
Use of Information Technology to Collect the Information
SSA did not create an electronic version of form SSA-104 under the agency’s Government Paperwork Elimination Act (GPEA) plan because only 25,000 respondents complete the form. This is less than the GPEA cut-off of 50,000.
Why We Cannot Use Duplicate Information
The nature of the information we are collecting and the manner in which we are collecting it preclude duplication. SSA does not use another collection instrument to obtain similar data.
Minimizing Burden on Small Respondents
This collection does not significantly affect small businesses or other small entities.
Consequence of Not Collecting Information or Collecting it Less Frequently
There are no technical or legal obstacles to burden reduction.
Special Circumstances
There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.
Solicitation of Public Comment and Other Consultations with the Public
The 60-day advance Federal Register Notice published on March 04, 2010, at 75 FR 9992, and we received no public comments. SSA published the second Notice on May 13, 2010 at 75 FR 27036. If we receive comments in response to the 30-day Notice, we will forward them to OMB.
We did not consult with the public on the revision of this form.
Payment or Gifts to Respondents
SSA does not provide payments or gifts to the respondents.
Assurances of Confidentiality
SSA protects and holds confidential the information it collects 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.
Justification for Sensitive Questions
The information collection does not contain any questions of a sensitive nature.
Estimates of Public Reporting Burden
Approximately 11,092 respondents take 10 minutes each to complete Form SSA-104 each year. Accordingly, the burden is 1,849 hours. This figure represents burden hours, and we did not calculate a separate cost burden
13. Annual Cost to the Respondents (Other)
This collection does not impose a known cost burden to the respondents.
Annual Cost To Federal Government
The annual cost to the Federal Government is approximately $17,082. This estimate is a projection of the costs 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 to 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 requirement 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.
Exceptions 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).
B. Collections of Information Employing Statistical Methods
SSA does not use statistical methods for this information collection.
| File Type | application/msword |
| File Title | Supporting Statement for |
| Author | robert mandelberg |
| Last Modified By | 889123 |
| File Modified | 2010-05-20 |
| File Created | 2010-05-20 |