Request for Workers' Compensation/Public Disability Benefit Information

ICR 201502-0960-001

OMB: 0960-0098

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Supplementary Document
2015-05-05
Supporting Statement A
2015-05-05
IC Document Collections
IC ID
Document
Title
Status
43695 Modified
ICR Details
0960-0098 201502-0960-001
Historical Active 201203-0960-012
SSA
Request for Workers' Compensation/Public Disability Benefit Information
Revision of a currently approved collection   No
Regular
Approved without change 08/24/2015
Retrieve Notice of Action (NOA) 05/13/2015
  Inventory as of this Action Requested Previously Approved
08/31/2018 36 Months From Approved 08/31/2015
120,000 0 120,000
30,000 0 30,000
0 0 0

SSA uses Form SSA-1709 to verify Worker's Compensation/Public Disability Benefits (WC/PDB). SSA uses the information to compute the correct reduction of disability insurance benefits. The claimants may be able to furnish adequate verification of the WC/PDB benefits by submitting a copy of their award notice, benefit check, etc. SSA considers the claimants the primary sources of verification; therefore, if they provide the necessary evidence, we do not use the form. If the claimants cannot provide evidence, the other reliable source of this information is the entity giving the benefits, its agent (such as an insurance carrier), or an administering public agency. The respondents are Federal, State, and local agencies, insurance carriers and public or private self-insured companies administering WC/PDB.

US Code: 42 USC 424a Name of Law: The Social Security Act
  
None

Not associated with rulemaking

  80 FR 9499 02/23/2015
80 FR 24307 04/30/2015
No

1
IC Title Form No. Form Name
SSA-1709 SSA-1709 Request for Worker's Compensation/Public Disability Benefit Information

  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 120,000 120,000 0 0 0 0
Annual Time Burden (Hours) 30,000 30,000 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$600,000
No
No
No
No
No
Uncollected
Faye Lipsky 410 965-8783 [email protected]

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
05/13/2015


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