Social Security Benefits Application

Forms and Documents

Document Name	Status
Form SSA-1 Medicare-only Paper Form SSA-1 Form and Instruction	Unchanged
Form SSA-16 Paper Form SSA-16 (Application for Disability Insurance Benefits ) Form and Instruction	Unchanged
Form SSA-2 Paper Form SSA-2 (Application for Wife's or Husband's Insurance Benefits) Form and Instruction	Unchanged
Form SSA-1 Paper Form SSA-1 (Application for Retirement Insurance Benefits) Form	Unchanged
Justification.doc Justification for No Material/Nonsubstantive Change	2011-04-26

IC Document Collections

IC ID	Document Title	Status
9628	1st Party Internet Social Security Benefits Application (iClaim) Other-Revised iClaim screens	Modified
194187	iAppointment Other-iAppointment Screens	Unchanged
191246	Medicare-only iClaim Other-Internet screens	Unchanged
191245	Medicare-only Paper Form SSA-1 Form and Instruction	Unchanged
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	Unchanged
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	Unchanged
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: 201104-0960-010
Status: Historical Inactive	Previous ICR Reference No: 201008-0960-006
Agency/Subagency: SSA	Agency Tracking No:
Title: Social Security Benefits Application
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn and continue	Conclusion Date: 05/20/2011
	Date Received in OIRA: 04/29/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2013	09/30/2013	09/30/2013
Responses	5,324,218	0	5,324,218
Time Burden (Hours)	1,281,889	0	1,281,889
Cost Burden (Dollars)	0	0	0

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Abstract: This ICR is for a change request to implement minor cosmetic changes (layout, etc.) to the online iClaim application. See collection instrument 1st Party Internet Social Security Benefits Application (iClaim) for screen shots.

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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:
	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

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

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)
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
Medicare-only iClaim
iAppointment

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Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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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]? No

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: 04/29/2011

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