Supporting_Statement--0448-(Revised)

Supporting Statement for Form SSA-2490-BK,

Application for Benefits Under a U.S.

International Social Security Agreement

20 CFR 404.1925

OMB No. 0960-0448

1. Justification

1. Introduction/Authoring Laws and Regulations

Section 233(a) of the Social Security Act (the Act) authorizes the President to enter into international Social Security agreements between the United States and foreign countries. Under such agreements, called totalization agreements, retirement, survivors, disability, and derivative benefits may be based on combined periods of coverage from the two agreement countries. 20 CFR 404.1925 of the Code of Federal Regulations states that if an applicant files for benefits from one country, that application can constitute an application for benefits from the other country, providing the applicant expresses intent to claim benefits from the other country. In order to assist the other country in determining a right to benefits under its law, or in identifying coverage under its social insurance system, each country obtains certain information from the applicant and exchanges that information with the other country

2. Description of Collection

Section 233(a) of (the Act) authorizes the President to broker international Social Security agreements (totalization agreements) between the United States and foreign countries. The Social Security Administration (SSA) collects information using form SSA-2490-BK to determine entitlement to Social Security benefits from the United States, or from a country that enters into a totalization agreement with the United States. The respondents are individuals applying for Old Age Survivors and Disability Insurance (OASDI) benefits from the United States or from a totalization agreement country.

Applicants applying for benefits from the United States under any Social Security agreement complete Form SSA-2490-BK through a U.S. claims taking facility, such as a Social Security field office, or Foreign Service Post, who are responsible for assisting them with the application. Applicants filing for foreign benefits at a U.S. claims taking facility will also complete Form SSA-2490-BK, except for applicants filing for foreign benefits under the agreements with Australia, Canada, Czech Republic, Japan, South Korea, and Spain. Applicants for benefits from the countries above will complete a special application form unique to those agreements.

Form SSA-2490-BK is available to SSA field offices through the Modernized Claims System version (MCS), which the FO uses when the person is filing for U.S. retirement or disability totalization benefits only, or U.S. retirement or disability totalization benefits and concurrently for foreign benefits. Form SSA-2490-BK is also available through SSA’s Intranet website as a print-only PDF through the Totalization Resource Kit.

3. Use of Information Technology to Collect the Information

Form SSA-2490-BK is available to SSA field offices through the Modernized Claims System version (MCS), which the FO uses when the person is filing for U.S. retirement or disability totalization benefits only, or U.S. retirement or disability totalization benefits and concurrently for foreign benefits. Form SSA-2490-BK is also available through SSA’s Intranet website as a print-only PDF through the Totalization Resource Kit.

In accordance with the agency’s Government Paperwork Elimination Act plan, SSA created an electronic version of form SSA-2490-Bk. Based on our data, we estimate approximately 70% of respondents under this OMB number use the electronic version.

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-2490-BK, we would not be able to determine eligibility of an applicant who expresses a desire to claim benefits. Additionally, we would not be able to fulfill obligations to obtain information that our agreement partners need to determine eligibility for benefits under their systems. Because we only collect the information on an as needed basic, 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 that inconsistent with 5 CFR 1320.5.

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

The 60-day advance Federal Register Notice published on June 15, 2011, at 76 FR 35067, and we received no public comments. The 30-day FRN published on

August 29, 2011 at 76 FR 53703. If we receive any comments in response to this Notice, we will forward them to OMB.

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

9. Payment or Gifts to Respondents

SSA does not provide payments 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

Form Number	Number of Respondents	Frequency of Response	Average Burden per Response (minutes)	Total Annual Burden (hours)
SSA-2490-BK (MCS)	14,000	1	30	7,000
SSA-2490-BK (paper)	2,000	1	30	1,000
Totals	16,000	-	-	8,000

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 $201,000.00. This estimate is a projection of costs for printing and distributing the form and for collecting the information.

15. Program Changes or Adjustments to the Information Collection Request

There has been a decrease in burden hours. This change stems from a decrease in the number of respondents applying for totalization agreements .

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. Collection of Information Employing Statistical Methods

SSA does not use statistical methods for this information collection.