Supporting Statement SSA-4111 (revised)

Supporting Statement for Form SSA-4111

Certificate of Election for Reduced Widow(er)’s and Surviving Divorced Spouse’s Benefits

20 CFR 404.335

OMB No. 0960-0759

1. Justification

1. Introduction/Authoring Laws and Regulations

Sections 202(e)(1)(C)(ii)(III) and 202(f)(1)(C)(ii)(III) of the Social Security Act (Act) and 20 CFR 404.335 of the Code of Federal Regulations, set forth the eligibility criteria and dates for the Certificate of Election for Reduced Widow(er)’s and Surviving Divorced Spouse’s Benefits can be file filled.

2. Description of Collection

Section 202 (q) of the Act provides for the authority to reduce benefits under certain conditions when elected by a Title II beneficiary. However, 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 elect reduced widow(er) benefits, a recipient completes Form SSA-4111. 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. The respondents are qualified dually entitled widow(er) s (or surviving divorced spouse) who elects to receive reduced widow (er) benefits.

The Social Security Administration (SSA) will conduct and collect this information collection when a recipient is required to report. An SSA employee can mail the recipient Form SSA-4111, the recipient can print Form SSA-4111 from the agency’s Internet website, or respondents can provide the information during a field office interview.

3. Use of Information Technology to Collect the Information

The recipient can mail the SSA-4111 to SSA, where a SSA employee enters the information into the MSSIC screens. A SSA employee can also enter the information into the MSSIC screens during a face-to-face interview. SSA did not create an electronic version of the form SSA-4111 under the agency’s Government Paperwork Elimination Act (GPEA) plan because only approximately 30,000 respondents complete the form. This is less than the GPEA cut-off of 50,000.

4. 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.

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

If we did not use Form SSA-4111, dually entitled widow(er) s or surviving divorced spouses would not receive reduced widow(er) benefits. This would be a violation of regulations at 20 CFR 404.355. Because we only collect the information once, we cannot collect it less frequently.

There are no technical or legal obstacles to burden reduction.

7. 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.

8. Solicitation of Public Comment and Other Consultations with the Public

SSA published the 60-day advance Federal Register Notice published on May 13, 2010, at 75 FR 27036, and we received no public comments. The second Notice published on August 02, 2010 at 75 FR 45190. If we receive comments in response to the 30-day Notice, we will forward them to OMB.

We did not consult with the public in the revision of this form.

9. Payment or Gift Respondents

SSA does not provide payment or gifts to the respondents.

10. 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.

11. Justification for Sensitive Questions

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

12. Estimates of Public Reporting Burden

Approximately 30,000 respondents take 2 minutes to complete form SSA-4111 each year. Accordingly, the burden is 1,000 hours. This figure represents burden hours, and we did not calculate a separate cost burden. There are no management information reports available that breaks down this workload. Since this is a post-eligibility workload handled in the processing center, we have no way to determine the number of in-person interviews conducted.

13. Annual Cost to the Respondents (Other)

This collection does not impose a known cost burden on the respondents.

14. Annual Cost to Federal Government

The annual cost to the Federal Government is approximately $75,417. This estimate is a projection of the costs for printing and distributing the collection instrument, 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.

18. 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).

2. Collections of Information Employing Statistical Methods

SSA does not use statistical methods for this information collection.

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