Supporting Statement
OMB No. 1510-NEW
Request for Payment of Federal Benefit by Check
(FMS Form 1201-W)
Justifications.
Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collection. Attach a copy of the appropriate section of each statute and regulation mandating or authorizing the collection of information.
The Debt Collection Improvement Act of 1996 requires that all Federal non-tax payments be made electronically. On December 22, 2010, Treasury issued a regulation at 31 CFR Part 208 that requires that all non-tax payments be made electronically, subject to limited waivers. Specifically, individuals with a mental impairment and/or who live in a remote geographic location that does not support the use of EFT may continue to receive payment by check. However, 31 CFR Part 208 requires individuals requesting one of these waiver conditions to submit a written justification that is notarized. In order to assist individuals with this submission, Treasury is preparing a waiver form so that all necessary information is collected.
Indicate how, by whom, and for what purpose the information is to be used. Except for a new collection, indicate the actual use the agency has made of the information received from the current collection.
Treasury’s fiscal agent, the Federal Reserve Bank of Dallas, operates the EFT waiver process on Treasury’s behalf. This office will receive and review these waiver request forms to ensure that they are completed properly and include a valid justification for a waiver from the EFT requirement, as outlined in 31 CFR Part 208. If the waiver is accepted, the Dallas representative will reflect this in their waiver database so the recipient can continue to receive payment by check.
Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g., permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden.
Only paper forms may be used in this process. Because the regulation requires that the waiver request be notarized, waivers cannot be submitted electronically.
Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above.
There are currently no processes or forms in place that request an individual to substantiate in writing why they cannot receive payment by EFT.
If the collection of information impacts small businesses or other small entities (Item 5 of OMB Form 83-I), describe any methods used to minimize burden.
Only individuals may request a waiver and therefore the collection of information applies only to individuals, not to small businesses or other small entities.
Describe the consequence to Federal program or policy activities if the collection is not conducted or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.
Failure to collect this information would violate the requirements of 31 CFR Part 208 and prevent individuals from exercising their right under the regulation to obtain a waiver from the EFT requirement.
Explain any special circumstances that would cause an information collection to be conducted in a manner: *requiring respondents to report information to the agency more often than quarterly; *requiring respondents to prepare a written response to a collection of information in fewer than 30 days after receipt of it; requiring respondents to submit more than an original and two copies of any document; etc.
The recipient must have the form notarized after it is completed. Incomplete forms, such as forms missing claim numbers, will be returned to the recipient to resubmit properly.
If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the agency’s notice, required by 5 CFR 1320.8(d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the agency in response to these comments. Specifically address comments received on cost and hour burden.
A 60-day notice was published in the Federal Register soliciting comments from the public on this new collection of information on December 13, 2011, at 76 FR 77590; no comments were received.
Explain any decision to provide any payment or gift to respondents, other than reenumeration of contractors or grantees.
N/A
Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulation, or agency policy.
The Privacy Act requires that agencies give the public notice of their systems of records by publication in the Federal Register. Treasury published a Systems of Record Notice amendment on July 19, 2011 (76 FR 42765), permitting Treasury to collect information necessary to facilitate the waiver process. The Privacy Act prohibits the disclosure of information from a system of records absent the written consent of the subject individual, unless the disclosure is pursuant to one of twelve statutory exceptions. The information collected from the form will only be used to determine if the recipient is eligible for a waiver from the EFT requirement or not, as outlined in 31 CFR Part 208.
Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private. This justification should include the reasons why the agency considers the questions necessary, the specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.
Individuals requesting a waiver from the EFT requirement due to a mental impairment must explain how the mental impairment necessitates receipt of their payments by paper check. This information will only be used to validate that a waiver is necessary and the information will not be disclosed to any other parties.
Provide estimates of the hour burden of the collection of information. The statement should: *indicate the number of respondents, frequency of response, annual hour burden; and an explanation of how the burden was estimated.
Based on Treasury goals for EFT, it is estimated that 3,000 recipients will apply for a waiver from the EFT requirement. They will only need to complete the waiver response one time, unless the form is incomplete and has to be returned to the recipient. The estimated annual burden hours are 3,000 (1 hour per form), which is based on the current completed waiver packet statistical data for the initial 6 month period carried out over the next 2, 6 month periods, including a 20% increase during the last period for late responders and 20 minutes to complete a one page form and provide a brief justification for a waiver and 40 minutes to have the form notarized (total of 1 hour per form).
# Respondents |
# Responses Per Respondent |
Annual Responses |
Hours Per Response |
Total Burden |
3,000 |
1 |
3,000 |
1 |
3,000 |
Provide an estimate for the total annual cost burden to respondents or recordkeepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).
It will cost the Government $1,320 in postage to mail the forms to recipients. Conversely, it will cost the recipients $1,320 in postage ($.44 each) to mail the completed forms to the waiver center in Dallas and an additional $15,000 (estimated $5 each) to have the form notarized by a notary public.
Provide estimates of annualized costs to the Federal government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operational expenses (such as equipment, overhead, printing, and support staff), and any other expense that would not have been incurred without this collection of information. Agencies may also aggregate cost estimates from Items 12, 13, and 14 in a single table.
The costs to administer the waiver process are included in Treasury’s overall reimbursement to the Federal Reserve Bank as a fiscal agent to operate the Go Direct program is $1,320 in postage.
Explain the reasons for any program changes or adjustments reported in Items 13 or 14 of the OMB Form 83-I.
This is new collection of information.
For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection of information, completion of report, publication dates, and other actions.
No results published.
If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.
We are seeking approval not to display the expiration date of the OMB approval. Identifying this date may cause confusion with the respondent on when form must be submitted to the bureau for consideration; as well as multiple printings of the form may reflect conflicting dates if older stock is retained for distribution.
Explain each exception to the certification statement identified in Item 19, “Certification for Paperwork Reduction Act Submissions,” of OMB Form 83-I.
N/A
B. Collections of Information Employing Statistical Methods
No statistical methods are being employed for this collection of information.
| File Type | application/msword |
| File Title | SUPPORTING STATEMENT |
| Author | cbrice |
| Last Modified By | Reference |
| File Modified | 2012-05-07 |
| File Created | 2012-05-07 |