OMB# 1076-0017 Fass Ss_final

Supporting Statement A

Financial Assistance and Social Services, 25 CFR 20

OMB Control Number 1076-0017

Terms of Clearance: None.

General Instructions

A completed Supporting Statement A must accompany each request for approval of a collection of information. The Supporting Statement must be prepared in the format described below, and must contain the information specified below. If an item is not applicable, provide a brief explanation. When the question “Does this ICR contain surveys, censuses, or employ statistical methods?” is checked "Yes," then a Supporting Statement B must be completed. OMB reserves the right to require the submission of additional information with respect to any request for approval.

Specific Instructions

Justification

1. Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collection.

The Bureau of Indian Affairs (BIA) provides assistance under 25 CFR 20 to eligible Indians when comparable financial assistance or social services either are not available or are not provided by state, tribal, county, local, or other federal agencies. The application form (BIA 5-6601) is necessary to determine eligibility for program funding and services, in accordance with 25 CFR 20.300. The Financial Assistance and Social Service (FASS) program funding and services include: General Assistance, Child Assistance, Adult Care Assistance, Burial Assistance, and Emergency Assistance. BIA and tribal case workers also obtain information from clients to develop an Individual Self-Sufficiency Plan (ISP). The ISP form (BIA 5-6602) is necessary to ensure that the recipient of services has a plan for achieving independence. Authority for 25 CFR 20 is contained in 25 U.S.C. 13, which provides that BIA shall direct, supervise and expend appropriated money for the benefit, care, and assistance of Indians, including for general support and civilization and relief of distress. Additional authority is provided by: Pub. L. 93–638; Pub. L. 98–473; Pub. L. 102–477; Pub. L. 104–193; and Pub. L. 105–83.

2. 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. Be specific. If this collection is a form or a questionnaire, every question needs to be justified.

Applicants must provide information on BIA Form 5-6601 “Application for Assistance/Services” to BIA to request services and document their eligibility for: § 20.325 (burial assistance), § 20.328 (disaster assistance), § 20.329 (emergency assistance), § 20.333 (adult care assistance), § 20.400 (children, elderly, families assistance), and § 20.500 (child assistance). BIA uses the information provided to determine eligibility for services, ensure uniformity of services, and assure the maintenance of current and accurate records for clear audit data. All information is collected and retained in secure individual case files. The information collected is also used for budgetary purposes and/or for responses to inquiries from other Federal agencies. The compilation of data allows for quick response to inquiries received.

BIA Form 5-6601 “Application for Assistance/Services” is used to identify the applicant and members of the household who may be eligible for service. Questions pertain to income, sources of income and demographic data such as age, date of birth, income and address. The first two pages of the application package contain instructions for the form, which begins on page 3.

The form requires the applicant’s name, tribe, tribal enrollment number, phone number, mailing address and physical address, as well as directions for how to get to the address. This information allows the BIA to identify and contact the applicant and allows the BIA case worker to locate the home. This section of the form also asks for background information on the reason for applying for assistance and the income on which the applicant has been living for the past 3 months - this information allows the BIA case worker to best match the types of assistance BIA can provide to the applicant’s needs.

• Section I of the form requests a list of members of the household, birth dates, sex, relation to head of household (applicant), marital status, highest grade/degree completed, social security number, and tribal enrollment #. BIA uses this information to identify each member of the household and determine whether the members qualify as dependents for the purposes of BIA assistance.

• Section II of the form requests the applicant to identify the type of service(s) requested.

• Section III of the form requests information on whether anyone in the household is earning income and, if so, the amounts earned. This section also requests the applicant to identify the types and amounts of all earned and unearned incomes. BIA compares this total to the state monthly standard and notes the difference as the monthly amount needed. The shaded portion of this section provides space for the BIA case worker to document the BIA decision to approve or disapprove. This section also requires information on whether the applicant has applied for Temporary Assistance for Needy Families (TANF) from the U.S. Department of Health and Human Services.

• Section IV of the form requires the applicant to acknowledge that he or she is not committing fraud. The client’s signature is required to indicate his/her request for assistance and is used for the release of information under the Privacy Act.

Pages 5 through 16 contains information that the BIA case worker will fill in based on information obtained through interviews. The top of page 5 identifies these pages as for BIA use only; these pages are also shaded to make clear that the applicant is not responsible for filling them out.

Pages 17 through 18 contain the required statements on Privacy Act, the Paperwork Reduction Act, Federal law concerning fraud, the right to appeal the BIA decision, information on eligibility, and reporting requirements.

Page 19 contains a Release of Information that the applicant may sign to acknowledge that BIA may release information for purposes directly connected with providing benefits or services on the applicant’s behalf or for legal and investigative action related to fraud. The release is effective for one year or until rescission (whichever is earlier).

BIA Form 5-6602 “Individual Self-Sufficiency/Case Plan” Once BIA has determined an applicant to be eligible, a BIA case worker works with the individual to fill out a standardized Individual Self-Sufficiency/Case Plan (ISP), pursuant to 25 CFR § 20.301. The individual provides information on his or her goals to achieve self-sufficiency and his or her strengths and barriers. Through discussions with the case worker, the individual and case worker then develop the steps and action plan for self-sufficiency. BIA has developed a new form to standardize this process. The case worker will fill out the form, based on discussions with the individual, or the individual will provide input directly onto the form. Both the case worker and individual sign the form.

3. 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 and specifically how this collection meets GPEA requirements.

This information collection activity’s use of electronic technology to collect the information, and thus reduce the burden, is accomplished by having case workers enter the information provided by the clients directly into their database. This does not preclude the tribal organizations from setting up a system that will enable them to easily provide the summary of reporting indicators. In addition, the application form is available on the BIA website and the standardized ISP is available on the BIA Intranet for Bureau personnel. Paper copies will continue to be made available, upon request. Tribes can request and obtain paper copies through commercial mail or by facsimile.

4. 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.

This is a unique program offered only to needy Indians who have no other recourse or resources available to them in order to meet basic essential needs. The information collection is specific to the applicant’s current situation and environment and is not available elsewhere.

5. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.

Indian tribes and tribal organizations are not considered small governmental jurisdictions or small entities as defined under the Regulatory Flexibility Act. The data collection will come from individuals applying for services from their federally-recognized tribe. However, the collection will not have a significant economic impact. Tribes that have elected to operate this program in lieu of receiving direct services from the BIA are required to use the information derived from the forms to determine eligibility for services of clients applying for services. The information requested on the form is the minimum needed.

6. 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.

Initial collection of this information is necessary to determine eligibility for services and to place an individual or assistance group on active or open case status. Open cases are reviewed on a semi-annual basis, for the purpose of re-determining eligibility. In addition, clients are required to report changes in their personal circumstances which may lead to adjustments in eligible services. Without the individual reporting mechanisms and the system of eligibility of re-determination, overpayments might go undetected. The limited funding available for this program requires careful distribution based upon need.

7. 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;

* requiring respondents to retain records, other than health, medical, government contract, grant-in-aid, or tax records, for more than three years;

* in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study;

* requiring the use of a statistical data classification that has not been reviewed and approved by OMB;

* that includes a pledge of confidentiality that is not supported by authority established in statute or regulation, that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or

* requiring respondents to submit proprietary trade secrets, or other confidential information, unless the agency can demonstrate that it has instituted procedures to protect the information's confidentiality to the extent permitted by law.

The Federal regulations governing this program, 25 CFR 20, require recipients to immediately inform the BIA of any changes in status that may affect their eligibility for or the amount of assistance; this could result in the recipient having to report information more often than quarterly. There are no other special circumstances that would cause information collection to be conducted in any of the above manners.

8. 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 in response to the PRA statement associated with the collection over the past three years, 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 for public comments was published in the Federal Register on February 20, 2014 (79 FR 9761). There were no comments received in response to this notice.

Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, the clarity of instructions and recordkeeping, disclosure, or reporting format (if any), and on the data elements to be recorded, disclosed, or reported.

Consultation with representatives of those from whom information is to be obtained or those who must compile records should occur at least once every three years — even if the collection of information activity is the same as in prior periods. There may be circumstances that may preclude consultation in a specific situation. These circumstances should be explained.

BIA case workers conduct ongoing review and discussion of this information collection with program staff when this form is completed and at various social service meetings conducted during the course of each fiscal year.

In addition, the BIA contacted Ms. Jennifer Pishion, Director at the Fallon Paiute Shoshone Tribal Business Council (Council), at [email protected]. Ms. Pishion indicated that the application form is user friendly and suggested a few unsubstantial changes. For instance, Ms. Pishion suggested that in Section 1, the applicant’s tribal enrollment number be added and the heading “Also Known As” be changed to ‘Other Names Used.” Ms. Pishion suggested that the Statement of Cooperation heading in Section IV be bolded and that applicants should provide their initial after each agreement. For efficiency purposes, Ms. Pishion thinks that the forms should be made available in a fillable format. The BIA made these minor changes, which will not have any impact on the burden estimates as a result of these comments. The BIA added the word “Enrollment Number” beside the applicant’s tribal affiliation in Section I. The form now inquires about “Other Names Used,” as opposed to asking for “Also Known As (see Section I). In Section IV, the Statement of Cooperation is now bolded and the applicant must initial after each agreement statement. Although the form can be accessed online, the BIA plans to make to make the forms fillable.

9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

No payments or gifts are provided to respondents.

10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulation, or agency policy.

There are assurances of confidentiality provided to the respondents for this information collection. The BIA complies with the requirements of the Privacy Act of 1974, as amended, to protect the privacy of respondents. The system of records for this collection was published in the Federal Register (76 FR 56787): System of Records BIA-8, Financial Assistance and Social Services – Case Management System.

11. 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.

Information about income, family relationships and demographic data are required to establish eligibility for a benefit. There are no other questions of a sensitive nature included in the information collected.

12. 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. Unless directed to do so, agencies should not conduct special surveys to obtain information on which to base hour burden estimates. Consultation with a sample (fewer than 10) of potential respondents is desirable. If the hour burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated hour burden, and explain the reasons for the variance. Generally, estimates should not include burden hours for customary and usual business practices.

* If this request for approval covers more than one form, provide separate hour burden estimates for each form and aggregate the hour burdens.

* Provide estimates of annualized cost to respondents for the hour burdens for collections of information, identifying and using appropriate wage rate categories. The cost of contracting out or paying outside parties for information collection activities should not be included here.

We estimate that on an average, there are 240,000 applications for assistance per year. Approximately 95,000 of the 240,000 respondents also provide information for an ISP. This results in an estimated annual burden of 215,000 hours or the equivalent annualized cost of $6,553,200.

Description	Respondents	Responses per Respondent	Burden Hours per Response	Total Burden Hours	Salary Cost ($30.48/hr)*
Application	240,000	1	0.5	120,000	$ 3,657,600
ISP	95,000	1	1	95,000	$ 2,895,600
				215,000	$ 6,553,200

*The applicants for the programs covered by Financial Assistance are usually unemployed or under employed.

The BIA is estimating salary using U.S. Department of Labor, Bureau of Labor Statistics (BLS), EMPLOYER COSTS FOR EMPLOYEE COMPENSATION – December 2013 (released March 12, 2014), USDL 14-0390, Table 1, for all civilians ($21.77/hour x 1.4 for benefits for individuals or $30.48/hour). The 1.4 multiplier is also derived from BLS, EMPLOYER COSTS FOR EMPLOYEE COMPENSATION – December 2013 (released March 12, 2014), USDL 14-0390. See www.bls.gov/news.release/pdf/ecec.pdf.

13. Provide an estimate of the total annual non-hour cost burden to respondents or recordkeepers resulting from the collection of information. (Do not include the cost of any hour burden already reflected in item 12.)

* The cost estimate should be split into two components: (a) a total capital and start-up cost component (annualized over its expected useful life) and (b) a total operation and maintenance and purchase of services component. The estimates should take into account costs associated with generating, maintaining, and disclosing or providing the information (including filing fees paid for form processing). Include descriptions of methods used to estimate major cost factors including system and technology acquisition, expected useful life of capital equipment, the discount rate(s), and the time period over which costs will be incurred. Capital and start-up costs include, among other items, preparations for collecting information such as purchasing computers and software; monitoring, sampling, drilling and testing equipment; and record storage facilities.

* If cost estimates are expected to vary widely, agencies should present ranges of cost burdens and explain the reasons for the variance. The cost of purchasing or contracting out information collection services should be a part of this cost burden estimate. In developing cost burden estimates, agencies may consult with a sample of respondents (fewer than 10), utilize the 60-day pre-OMB submission public comment process and use existing economic or regulatory impact analysis associated with the rulemaking containing the information collection, as appropriate.

* Generally, estimates should not include purchases of equipment or services, or portions thereof, made: (1) prior to October 1, 1995, (2) to achieve regulatory compliance with requirements not associated with the information collection, (3) for reasons other than to provide information or keep records for the government or (4) as part of customary and usual business or private practices.

The annual cost burden to respondents from total capital and startup costs is estimated to be zero because financial assistance funds are provided to cover administrative costs for tribes managing the program.

14. Provide estimates of annualized cost 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.

The estimated annualized cost to the Federal Government for this information collection is summarized in the table below.

Description	Respondents	Responses per Respondent	Federal Burden Hours per Response	Total Burden Hours	Salary Cost ($29.75/hr)*
Application	240,000	1	3*	720,000	$21,420,000
ISP	95,000	1	1	95,000	$2,826,250
				815,000	$24,246,250

* Based on a range from 1/4 hour to 8 hours because of the varying amount of time it takes to verify the information submitted on the application.

The salaries range from the equivalent of GS-7/5 to GS-9/8 ($18.64 X 1.4 = $26.10 to $24.81 X 1.4 = $34.73). For this reason, we use GS-8/6 as the average salary ($21.25 X 1.4 = $29.75). See https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/2014/general-schedule/. These salaries are from the Salary Table 2014-GS Incorporating the 1% General Schedule Increase. While this is Federal and normally would use 1.5 as the multiplier for benefits, because the tribes are collecting the information under contract for us, we are using 1.4 as the multiplier. The 1.4 multiplier is also derived from BLS, EMPLOYER COSTS FOR EMPLOYEE COMPENSATION – December 2013 (released March 12, 2014), USDL 14-0390. See www.bls.gov/news.release/pdf/ecec.pdf.

15. Explain the reasons for any program changes or adjustments in hour or cost burden.

The program made minor changes to the forms to add clarity which does not impact the hour or cost burden. There are no program changes.

16. 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.

There are no plans to publish the results of this collection of information. However, a summary may be used for budget justification.

17. 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 will display the OMB control number and expiration date on the forms.

18. Explain each exception to the topics of the certification statement identified in "Certification for Paperwork Reduction Act Submissions."

There are no exceptions.

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