Modified Benefit Formula Questionnaire-Foreign Pension

Forms and Documents

Document Name	Status
Form SSA-308 Modified Benefit Formula Questionnaire-Foreign Pension Form	Unchanged
Greenberg_Notice_Short form_OMB.doc Supplementary Document	2014-10-21
Draft Opt-Out Form v3.DOCX Supplementary Document	2014-10-21
Draft Form To Request Settlement Claim Review v2.DOCX Supplementary Document	2014-10-21
0960-0561 change request (due to Greenberg lawsuit).doc Justification for No Material/Nonsubstantive Change	2014-10-21

IC Document Collections

IC ID	Document Title	Status
9495	Modified Benefit Formula Questionnaire-Foreign Pension Form	Unchanged
213556	Modified Benefit Formula Questionnaire – Foreign Pension Class Members Other-Telephone interview	New

ICR Details

OMB Control No: 0960-0561	ICR Reference No: 201410-0960-003
Status: Historical Active	Previous ICR Reference No: 201110-0960-002
Agency/Subagency: SSA	Agency Tracking No:
Title: Modified Benefit Formula Questionnaire-Foreign Pension
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: 10/23/2014
	Date Received in OIRA: 10/21/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2015	02/28/2015	02/28/2015
Responses	15,118	0	13,452
Time Burden (Hours)	3,908	0	2,242
Cost Burden (Dollars)	0	0	0

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Abstract: SSA uses the information Form SSA-308 collects to determine exactly how much (if any) of a foreign pension may be used to reduce the amount of title II Social Security retirement or disability benefits under the modified benefit formula. The respondents are applicants for title II Social Security or disability benefits who have foreign pensions. In this non-substantive change request, SSA is adding a new group of respondents - class members of the lawsuit Greenberg vs. Colvin.

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Authorizing Statute(s): US Code: 42 USC 415 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 68805	11/07/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 2114	01/13/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Modified Benefit Formula Questionnaire-Foreign Pension	SSA-308	Modified Benefit Formula Questionnaire--Foreign Pension
Modified Benefit Formula Questionnaire – Foreign Pension Class Members

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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	15,118	13,452	0	1,666	0	0
Annual Time Burden (Hours)	3,908	2,242	0	1,666	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: Greenberg, et al. v. Colvin, et al., Case No. 1:13-cv-01837-RMC, as a class action for settlement purposes under Federal Rule of Civil Procedure 23(b)(3). The class, as defined in the settlement agreement, is comprised of Social Security beneficiaries whose Social Security old age, survivors, and disability insurance benefits payments (OASDI Benefits) were reduced (or who were assessed overpayments) since September 3, 2004, through application of the Windfall Elimination Provision (WEP), based on their receipt of Old Age Benefits from the National Institute of Israel (NII Old-Age Benefits). SSA plans to collect information relating to the Class member's pension(s) in the following ways: 1) via a dedicated PO Box which will be used as a repository for the submission of all documents, including the Settlement Review Request form, mailed by the Class member with respect to his or her request for a review of their record; 2) by responding to phone calls via the dedicated toll-free line with respect to his or her request for a review of their record; 3) by having an SSA employee key in information on Intranet and secure systems' screens, should the Class member visit his or her local field office; and 4) via correspondence or communication from Class Counsel on behalf of the Class member.

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Annual Cost to Federal Government: $77,000

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: 10/21/2014

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