supporting_statement_(revised)_0003

Supporting Statement for Form SSA-5-F6

Application for Mother’s or Father’s Insurance Benefits

20 CFR 404.339-404.342, 20 CFR 404.601-404.603

OMB No. 0960-0003

A. Justification

1. Introduction/Authoring Laws and Regulations

Section 202(g) of the Social Security Act (the Act) provides for the payment of monthly benefits to the widow or widower of an insured individual if the surviving spouse is caring for a child of the deceased worker who is entitled to Social Security benefits.

The regulatory requirements for implementing Section 202(g) of the Act are set forth in 20 CFR 404.339–404.342 and 20 CFR 404.601–404.603 of the Code of Federal Regulations.

2. Description of Collection

The Social Security Administration (SSA) uses the information on Form

SSA-5-F6 to determine an individual’s eligibility for mother’s or father’s insurance benefits. The respondents are individuals caring for a child of the deceased worker who is applying for mother’s or father’s insurance benefits under the Old Age, Survivors, and Disability Insurance (OASDI) program.

3. Use of Information Technology to Collect the Information

A print version of Form SSA-5-BK is available as a PDF on SSA’s website. SSA also collect the information on the paper Form SSA-5-BK electronically using SSA’s Modernized Claims System.

In accordance with the agency’s Government Paperwork Elimination Act plan, SSA created an electronic version of form SSA-5-BK. Based on our data, we estimate approximately 97% 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-5-BK, eligible individuals would have no way to apply for mother’s or father’s insurance benefits. Because we collect this information on an as needed basis, 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 inconsistent with 5 CFR 1320.5.

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

The 60-day advance Federal Register Notice published on December 15, 2011, at 76 FR 78068, and we received no public comments. The 30-day FRN published on February 29, 2012 at 77 FR 12350. If we receive any comments in response to this Notice, we will forward them to OMB.

Note: The first Federal Register Notice shows incorrect burden information for the SSA-5-F6. We have corrected for this in the second Notice, in #12 below and on ROCIS.

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

Collection Method	Number of respondents	Frequency of response	Average Burden per response (minutes)	Estimated total annual burden (hours)
SSA-5-BK (paper)	1,611	1	15	403
MCS	26,045	1	15	6,511
MCS/Signature Proxy	26,044	1	14	6,077
Totals	53,700			12,991

13. Annual Cost to the Respondents (Other)

There is no known cost burden to the respondents.

14. Annual Cost to Federal Government

The annual cost to the Federal government for the paper form is approximately $413,490. This estimate is 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

There has been an increase in the burden hours. The change stems from an increase in the number of applicants for mother’s or father’s benefits.

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.

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