Supporting Statement 0534 (revised)

Supporting Statement for Form SSA-773-U4

Waiver of Right to Appear – Disability Hearing

20 CFR 404.913-.914, 404.916(b)(5), 416.1413-.1414, 416.1416(b)(5)

OMB No. 0960-0534

A. Justification

1. Introduction/Authoring Laws and Regulations

Section 205(b) of the Social Security Act (the Act) and Sections 20 CFR 404.913-.914 and 20 CFR 416.1413-.1414 of the Code of Federal Regulations (CFR) allow for an evidentiary hearing at the reconsideration level of appeal for claimants who received an initial or revised determination that a disability did not exist or has ceased. 20 CFR 404.916(b)(5) and 20 CFR 416.1416(b)(5) of the CFR informs the claimants on the effects of their decision to waive the right to a hearing.

2. Description of Collection

Claimants for Social Security disability payments or their representatives can use

Form SSA-773-U4 to officially waive their right to appear at a disability hearing. The disability hearing officer uses the signed form as a basis for not holding a hearing, and for preparing a written decision on the claimant’s request for disability payments based solely on the evidence of record. The respondents are claimants for disability under title II and title XVI of the Act, or their representatives, who wish to waive their right to appear at a disability hearing.

3. Use of Information Technology to Collect Information

Form SSA-773-U4 is available through the Internet in a portable document format

(PDF) for the public to download, print, fill out, and send to SSA for processing. Paper copies of the form are also available to claimants. The respondent mails or provides a copy of the completed form to SSA.

SSA did not create an electronic version of Form SSA-773-U4 under the agency’s Government Paperwork Elimination Act (GPEA) plan because only 200 respondents complete the form. This is less than the GPEA cut-off of 50,000.

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-773, claimants would not have a structured format in which to request a waiver to appear for a hearing, or documentation informing them of the effects of their decision to waive that right. SSA would also lack documentation of the claimants’ informed decision. Since SSA requests this information on an as needed basis, we cannot collect it less frequently.

There are no technical or legal obstacles that prevent 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

SSA published the 60-day advance Federal Register Notice on March 30, 2012, at

77 FR 19406, and we received no public comments. We published the 30-day Federal Register Notice on June 14, 2012 at 77 FR 35739. If we receive comments in response to the 30-day Notice, we will forward them to OMB. There have been no outside consultations with members of the public.

9. Payment of Gifts to Respondents

SSA does not provide payments or gifts to the respondents.

10. Assurances of Confidentiality

SSA protects and holds confidential the information from this collection 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 Instrument	Number of Respondents	Frequency of Response	Average Burden per Response (minutes)	Estimated Total Annual Burden (hours)
SSA-773-U4	200	1	3	10

Approximately 200 respondents take 3 minutes each to complete form SSA-773-U4 each year. Accordingly, the burden is 10 hours. This figure represents burden hours, and we did not calculate a separate cost burden.

13. Annual Cost to the Respondents

This collection does not impose a known cost burden on the respondents.

14. Annual Cost to the Federal Government

The annual cost to the Federal Government is approximately $308. This estimate is for printing and distributing the collection instrument and for collecting the information.

15. Program Changes or Adjustments to the Information Collection Request

There are no changes in the public reporting burden.

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 requirements 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. Exception 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 did not use statistical methods for this information collection.