3220-0034

OMB NO. 3220-0034

Justification

Statement of Authority to Act for Employee

RRB Form SI-10

1. Circumstances of information collection - Under Section 5(a) of the Railroad Unemployment Insurance Act (RUIA) claims for benefits under that Act are to be made in accordance with such regulations as the Railroad Retirement Board (RRB) shall prescribe. The provisions for claiming sickness benefits as provided by Section 2 of the RUIA are prescribed in 20 CFR 335.2. Included in these provisions is the RRB's acceptance of someone signing forms on behalf of the employee, if the RRB is satisfied that the employee is sick or injured to the extent of being unable to sign forms.

20 CFR 348, Representative Payment under the Railroad Unemployment Insurance Act, addresses situations where there is evidence of guardianship or incompetence, and the RRB determines that the appointment of a representative payee for the beneficiary is necessary. Form SI-10, Statement of Authority to Act for Employee, is not prescribed for use in the process of appointing a representative payee. Instead, Form SI-10 is used when the beneficiary, though competent to handle his or her own affairs, is sick or injured to the extent of being unable to sign forms.

2. Purpose of collecting/consequences of not collecting the information - Form SI-10, Statement of Authority to Act for Employee, has two purposes; to provides the means for an individual to apply for authority to act on behalf of an incapacitated employee and to provide the means for the RRB to obtain the information necessary to satisfy itself that the delegation should be made. Form SI‑10 is provided both as a stand-alone form and as part of Forms SI-1a, Application for Sickness Benefits, and SI-1b, Statement of Sickness (3220-0039). Section 1 of the SI-10 is completed by the applicant for the authority and Section 2 is completed by the employee's doctor. Completion of the form is self-explanatory.

When possible, the form is preprinted by the initiating field office with the name, social security number, and address of the incapacitated employee. After Sections 1 and 2 are completed by the applicant and the employee's doctor, respectively, the form is returned by the applicant to the initiating field office in a self-return envelope provided by the RRB, or to the RRB headquarters in Chicago.

The RRB proposes no changes to Form SI-10.

To our knowledge, no other agency uses a form similar to Form SI-10.

3. Planned use of improved information technology or technical/legal impediments to further burden reduction - Not cost effective due to low volume.

4. Efforts to identify duplication - This information collection does not duplicate any other information collection.

5. Small business respondents - N.A.

6 Consequences of less frequent collection - Not applicable since the information is obtained only once.

7. Special circumstances - N.A.

8. Public comments/consultations outside the agency - In accordance with 5 CFR 1320.8(d), comments were invited from the public regarding this information collection. The notice to the public was published on page 24066 of the April 29, 2011, Federal Register. No comments or requests for additional information were received.

9. Payments or gifts to respondents - None

10. Confidentiality - Privacy Act System of Records, RRB-21, Railroad Unemployment and Sickness Insurance Benefit System - An RRB Privacy Impact Assessment that includes RRB-21 can be found at the following link: http://www.rrb.gov/pdf/PIA/PIA-BPO.pdf.

11. Sensitive questions - N.A.

12. Estimate of respondent burden - The estimated burden for this collection remains unchanged at 400 responses and 40 burden hours annually.

13. Estimated annual cost to respondents or record keepers - N.A.

14. Estimate of cost to Federal Government - N.A.

15. Explanation for change in burden - N.A

16. Time schedule for data collections and publications - The results of this collection will not be published.

17. Request not to display OMB expiration date - The SI-10 is a low usage form that is seldom revised. Given the costs associated with redrafting, reprinting, and distributing the form in order to keep the appropriate OMB expiration date in place, the RRB requests the authority to not display the OMB expiration date on the form.

18. Exceptions to Certification Statement – None.

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