Statement Regarding Date of Birth and Citizenship

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-702 Statement Regarding Date of Birth and Citizenship	Form	Modified	Available
0016 Supporting Statement (revised).doc	Supporting Statement A	Uploaded 2014-07-24	Available
0016 Addendum.doc	Supplementary Document	Uploaded 2014-05-09	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8904	Statement Regarding Date of Birth and Citizenship	Form	Modified

ICR Details

OMB Control No: 0960-0016	ICR Reference No: 201404-0960-012
Status: Historical Active	Previous ICR Reference No: 201105-0960-005
Agency/Subagency: SSA	Agency Tracking No:
Title: Statement Regarding Date of Birth and Citizenship
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: 10/20/2014
	Date Received in OIRA: 07/25/2014
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2017	36 Months From Approved	10/31/2014
Responses	1,200	0	1,200
Time Burden (Hours)	200	0	200
Cost Burden (Dollars)	0	0	0

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Abstract: SSA uses Form SSA-702 to collect information when preferred or other evidence is not available to prove age or citizenship for an individual applying for Social Security benefits. SSA uses this form for individuals who must establish age as a factor of entitlement or U.S. citizenship as a payment factor. Respondents are individuals with knowledge about the date of birth or citizenship of applicants for one or more Social Security benefits who need to establish their dates of birth as a factor of entitlement or U.S. citizenship as a factor of payment.

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Authorizing Statute(s): PL: Pub.L. 104 - 193 401 Name of Law: Personal Responsibility and Work Opportunity Reconciliation Act of 1996
   US Code: 42 USC 405 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:
	79 FR 26798	05/09/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 42863	07/23/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Statement Regarding Date of Birth and Citizenship	SSA-702	Statement Regarding Date of Birth and Citizenship

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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	1,200	1,200	0	0	0	0
Annual Time Burden (Hours)	200	200	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: $1,848

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: 07/25/2014

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