Social Security Benefits Application

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-1 Medicare-only Paper Form SSA-1	Form and Instruction	Modified	Available
Form SSA-16 Paper Form SSA-16 (Application for Disability Insurance Benefits )	Form and Instruction	Modified	Available
Form SSA-2 Paper Form SSA-2 (Application for Wife's or Husband's Insurance Benefits)	Form and Instruction	Modified	Repair queued
Form SSA-1 Paper Form SSA-1 (Application for Retirement Insurance Benefits)	Form	Modified	Available
Addendum - 0618 (Final).doc	Supplementary Document	Uploaded 2010-08-18	Available
Supporting Statement - 0618 (Final).doc	Supporting Statement A	Uploaded 2010-08-18	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9628	1st Party Internet Social Security Benefits Application (iClaim)	Other-Revised iClaim screens	Modified
194187	iAppointment	Other-iAppointment Screens	New
191246	Medicare-only iClaim	Other-Internet screens	Modified
191245	Medicare-only Paper Form SSA-1	Form and Instruction	Modified
191244	Medicare-only MCS screens	Other-MCS screens for Medicare-only (will be modified in intervi	Unchanged
184984	Notices to Beneficiaries who Have Third Parties Applying for them Via iClaim	Other-Notices to Beneficiaries with 3rd-party iClaim completion	Unchanged
184982	3rd Party iClaim	Other-iClaim screens -- for 3rd parties	Modified
179349	Paper Form SSA-16 (Application for Disability Insurance Benefits )	Form and Instruction	Modified
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	Modified
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	Unchanged
179334	SSA-1 MCS Screens	Other-MCS Screens	Unchanged

ICR Details

OMB Control No: 0960-0618	ICR Reference No: 201008-0960-006
Status: Historical Active	Previous ICR Reference No: 201006-0960-014
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: 09/30/2010
	Date Received in OIRA: 08/18/2010
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2013	36 Months From Approved	01/31/2013
Responses	5,324,218	0	5,124,218
Time Burden (Hours)	1,281,889	0	1,248,556
Cost Burden (Dollars)	0	0	0

---

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.

---

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

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 9992	03/04/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 51153	08/18/2010
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 16

table that charts list of burden

IC Title	Form No.	Form Name
Notices to Beneficiaries who Have Third Parties Applying for them Via iClaim
1st Party Internet Social Security Benefits Application (iClaim)
Medicare-only iClaim
iAppointment
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
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

---

ICR Summary of Burden

table that charts list 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	5,324,218	5,124,218	0	200,000	0	0
Annual Time Burden (Hours)	1,281,889	1,248,556	0	33,333	0	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: No

Burden Reduction Due to:

Short Statement: The increase in the public reporting burden is due to the addition of iAppointment. There are no changes or adjustments to the public reporting burden related to the new revisions to the iClaim screens or the paper Forms SSA-1, SSA-2 and SSA-16.

---

Annual Cost to Federal Government: $7,735,300

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]? No

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

---

Common Form ICR:  No

---

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: 08/18/2010

---