Application for Supplemental Security Income

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-8001-BK Application for Supplemental Security Income	Form	Modified	Available
Addendum_to_Supporting_Statement_0444.doc	Supplementary Document	Uploaded 2012-08-06	Available
Supporting Statement (revised).doc	Supporting Statement A	Uploaded 2012-04-03	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9319	Application for Supplemental Security Income MSSICS	Other-MSSICS Screen	Modified
188727	Application for Supplemental Security Income	Form	Modified
188726	Application for Supplemental Security Income MSSICS/Signature Proxy	Other-MSSIC/Signature Proxy	Modified

ICR Details

OMB Control No: 0960-0444	ICR Reference No: 201112-0960-002
Status: Historical Active	Previous ICR Reference No: 200909-0960-004
Agency/Subagency: SSA	Agency Tracking No:
Title: Application for Supplemental Security Income
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/06/2012
	Date Received in OIRA: 05/02/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2015	36 Months From Approved	08/31/2012
Responses	1,360,000	0	967,531
Time Burden (Hours)	335,920	0	238,900
Cost Burden (Dollars)	0	0	0

---

Abstract: SSA collects information on the SSA-8001-BK to determine an applicant's eligibility for SSI and the SSI payment amounts. SSA employees also collect this information during interviews with members of the public who wish to file for SSI. SSA uses the information for two purposes: (1) To formally deny SSI for non- medical reasons when information the applicant provides results in ineligibility; or (2) to establish a disability claim, but defer the complete development of non-medical issues until SSA approves the disability. The respondents are recipients for SSI benefits.

---

Authorizing Statute(s): US Code: 42 USC 1383 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 147	01/03/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 19406	03/30/2012
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Application for Supplemental Security Income MSSICS
Application for Supplemental Security Income MSSICS/Signature Proxy
Application for Supplemental Security Income	SSA-8001-BK	Application For Supplemental Security Income

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,360,000	967,531	0	89,355	303,114	0
Annual Time Burden (Hours)	335,920	238,900	0	20,849	76,171	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: There has been an increase in burden hours. This change stems from an increase in the number of respondents applying for benefits.

---

Annual Cost to Federal Government: $149,002

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

---

Common Form ICR:  No

---

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: 05/02/2012

---