Claim Against the United States for the Proceeds of a Government Check

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form FMS 1133-A Claim Against the United States for Proceeds of a Government Check (SSA)	Form and Instruction	Modified	Available
Form FMS 1133 Claim Against the United States for the Proceeds of a Government Check	Form and Instruction	Modified	Repair queued
1530-0010_SS_FMS_1133_FINALv3.doc	Supporting Statement A	Uploaded 2015-01-26	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
15380	Claim Against the United States for the Proceeds of a Government Check	Form and Instruction	Modified	Claim Against the United States for Proceeds of a Government Check (SSA)
15380	Claim Against the United States for the Proceeds of a Government Check	Form and Instruction	Modified	Claim Against the United States for the Proceeds of a Government Check

ICR Details

OMB Control No: 1530-0010	ICR Reference No: 201412-1530-002
Status: Historical Active	Previous ICR Reference No: 201407-1530-010
Agency/Subagency: TREAS/FISCAL	Agency Tracking No:
Title: Claim Against the United States for the Proceeds of a Government Check
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: 02/25/2015
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/26/2015
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2018	36 Months From Approved	11/30/2016
Responses	51,640	0	27,640
Time Burden (Hours)	8,609	0	4,608
Cost Burden (Dollars)	0	0	0

---

Abstract: This series of forms are used to collect information needed to process an individual's claim for non-receipt of proceeds from a U.S. Treasury check or electronic benefit payments. Once the information is analyzed, a determination is made and a recommendation is submitted to the program agency to either settle or deny the claim.

---

Authorizing Statute(s): US Code: 31 USC Sec. 321, 3331-3343 Name of Law: Money and Finance; General authority of the Secretary
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 46301	08/07/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 4037	01/26/2015
Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

IC Title	Form No.	Form Name
Claim Against the United States for the Proceeds of a Government Check	FMS 1133-A, FMS 1133	Claim Against the United States for the Proceeds of a Government Check ,   Claim Against the United States for Proceeds of a Government Check (SSA)

---

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	51,640	27,640	0	24,000	0	0
Annual Time Burden (Hours)	8,609	4,608	0	4,001	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: An increase of 24,000 responses and 4,001 burden hours is a program change based on the introduction of the new form FMS 1133-A. The new form addresses non-receipt of electronic benefit payments from the SSA.

---

Annual Cost to Federal Government: $377,500

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

---

Common Form ICR:  No

---

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: 01/26/2015

---