Authorization to Disclose Information to the Social Security Administration

Forms and Documents

Document	Type	Status	Availability
Form SSA-827 SSA-827 with wet signature	Form and Instruction	Modified	Repair queued
Justification for Non-Substantive Changes 0960-0623.doc	Justification for No Material/Nonsubstantive Change	Uploaded 2013-11-13	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
9639	SSA-827 with wet signature	Form and Instruction	Modified
197969	SSA-827 (with electronic signature(adult first person only)	Other-Internal Screens	Modified
183732	Reading the Internet Instructions	Instruction	Unchanged

ICR Details

OMB Control No: 0960-0623	ICR Reference No: 201311-0960-004
Status: Historical Active	Previous ICR Reference No: 201305-0960-001
Agency/Subagency: SSA	Agency Tracking No:
Title: Authorization to Disclose Information to the Social Security Administration
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/21/2013
	Date Received in OIRA: 11/19/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2014	10/31/2014	10/31/2014
Responses	4,829,651	0	4,829,651
Time Burden (Hours)	677,161	0	677,161
Cost Burden (Dollars)	0	0	0

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Abstract: Adding a fillable PDF version of the collection instrument; this action does not affect the public reporting burden. SSA must obtain sufficient evidence to make eligibility determinations for Title II and Title XVI payments. Therefore, the applicant must authorize release of information from various sources to SSA. The applicant uses the SSA–827 to provide consent for the release of medical records, education records, and other information related to his or her ability to perform tasks. Once the applicant completes the SSA–827, SSA or the State Disability Determination Service sends the form to the designated source(s) to obtain pertinent records. The respondents are applicants for TitleII benefits and Title XVI payments. This Non-Substantive Change Request includes finalized screens for in-person or telephone interview attestation for childhood claims.

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Authorizing Statute(s): US Code: 42 USC 405 Name of Law: Social Security Act
   US Code: 42 USC 1383 Name of Law: Social Security Act
   US Code: 42 USC 423 Name of Law: Social Security Act
   US Code: 42 USC 1382c Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 23640	04/27/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 53703	08/29/2011
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
SSA-827 with wet signature	SSA-827, SSA-827	Authorization To Disclose Information To The Social Security Administration ,   Fillable PDF Version
Reading the Internet Instructions
SSA-827 (with electronic signature(adult first person only)

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ICR Summary 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	4,829,651	4,829,651	0	0	0	0
Annual Time Burden (Hours)	677,161	677,161	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $10,386,309

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

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Common Form ICR:  No

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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: 11/19/2013

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