Supporting Statment 0671

Supporting Statement for Form HA-504,

Acknowledgement of Receipt (Notice of Hearing)

20 CFR 404.938 and 416.1438

OMB No. 0960-0671

A. Justification

1. Introduction/Authoring Law and Regulations - Sections 205(b)(1) and 1631(c)(1)(A) and (B) of the Social Security Act (Act) and 20 CFR 404.938 and 416.1438 of the Code of Federal Regulations (Code) authorize the Social Security Administration (SSA) to collect the information on Form HA-504. The Act and the regulations require claimants to acknowledgment receipt of the Notice of Hearing and indicate whether they will attend the hearing as shown on the notice. Sections 205(d) and 1631(c) of the Act, as well as 20 CFR 404.936(d), (e), (f), 404.950(a), 416.1436(d), (e), (f); and 416.1450(a) of the Code authorize SSA to 1) establish the time and place of the hearing and 2) request claimants to present evidence during the hearing.

2. Description of Collection - SSA uses Form HA-504 as the claimants’ acknowledgement of receipt for the Notice of Hearing issued by an administrative law judge (ALJ), establishes the time and place of the hearing, and reminds claimants to gather evidence in support of their claim. There are two versions of this form, the HA-504 and the HA-504-OP1. The only difference between the two forms is the exclusion of the video teleconferencing option on the HA-504-OP1. SSA determines which version of the form to use based on where the claimant lives, and where the ALJ and experts involved in the case are located. If SSA can conduct the hearing via teleconferencing, we send the HA-504 and attempt to schedule a teleconference. We estimate approximately 10 percent of all hearings are conducted via teleconferencing.

Depending on the claimant’s response, the ALJ will either: 1) prepare for the hearing as scheduled; or 2) reschedule the hearing for a different date and/or location. In situations where claimants do not want a video hearing, the ALJ reschedules the hearing as a face-to-face hearing. The respondents are applicants for Social Security benefits who request a hearing to appeal an unfavorable entitlement or eligibility determination.

3. Use of Information Technology to Collect the Information - The HA-504 is not currently available electronically. SSA prioritizes collections that will become electronic; higher volume collections, as well as those that are legally mandated, take precedence to this one. However, we do accept responses through email and fax.

4. Why We Cannot Use Duplicate Information - The information the ALJ collects on this form does not duplicate information already presented by the claimant, nor is it information easily provided any other source other than the claimant. The information collected is essential for the orderly functioning of the hearing process and safeguards claimants’ rights under the law and regulations.

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 collect the information, it would disrupt the hearing process for both the claimant and the agency, and could violate statutory and regulatory requirements relating to fair hearings and due process. Therefore, we cannot collect this information less frequently. There are no technical or legal obstacles that prevent 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 on November 12, 2010, at 75 FR 69515, and we received no public comments. We published the 30-day Notice on January 20, 2010 at 76 FR 3688. If we receive any comments in response to the 30-day Notice, we will forward them to OMB.

9. Payment or Gifts to Respondents - SSA provides no payment or gifts to the respondents.

10. Assurances of Confidentiality – SSA protects and holds confidential the information 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 700,000 respondents use the two versions of Form HA-504 annually. The estimated average response time is 30 minutes to complete the form and gather evidence for the hearing, for 350,000 burden hours as reflected in the chart below:

Version of the HA-504	Number of Respondents	Frequency of Response	Average Burden Per Response (minutes)	Total Annual Burden (hours)
HA-504 (with Teleconferencing)	70,000	1	30	35,000
HA-504-OP1 (without Teleconferencing)	630,000	1	30	315,000
Totals	700,000			350,000

The total burden reflects burden hours and we did not calculate a separate cost burden.

13. Annual Cost to the Respondents - There is no known cost burden to the respondents.

14. Annual Cost to the Federal Government - The annual cost to the Federal Government is approximately $264,786 as 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 - The increase in the annual reporting burden is due an adjustment increase in the number of respondents since 2007.

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).

B. Collections of Information Employing Statistical Methods

SSA does not use statistical methods for this information collection.

3