Supporting Statement
OMB No. 1530-0019
Request for Payment of Federal Benefit by Check
(FS Form 1201W & FS 1201W-DFAS)
Justifications.
Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collection. Attach a copy of the appropriate section of each statute and regulation mandating or authorizing the collection of information.
The Debt Collection Improvement Act of 1996 requires that all Federal non-tax payments be made electronically. On December 22, 2010, Treasury issued a regulation at 31 CFR Part 208 that requires that all non-tax payments be made electronically, subject to limited waivers. Specifically, individuals with a mental impairment and/or who live in a remote geographic location that does not support the use of EFT may continue to receive payment by check. However, 31 CFR Part 208 requires individuals requesting one of these waiver conditions to submit a written justification that is notarized. The notary requirement was later removed because it proved to be difficult for some recipients to obtain. Form FS 1201W was created to assist individuals with this submission.
The Defense Finance and Accounting Service (DFAS), Department of Defense, has asked Treasury to assist them in reviewing and approving or rejecting requests by their recipients of a military benefit to continue receiving payment by check. Fiscal Service will offer DFAS users the FS 1201W-DFAS, which is the same as the FS-1201W except for a few modifications to accommodate military benefits recipients.
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.
Treasury’s fiscal agent, the Federal Reserve Bank of Dallas, operates the EFT waiver process on Treasury’s behalf. This office will receive and review these waiver request forms to ensure that they are completed properly and include a valid justification for a waiver from the EFT requirement, as outlined in 31 CFR Part 208. If the waiver is accepted, the Dallas representative will reflect this in their waiver database so the recipient can continue to receive payment by check.
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? What consideration is given to use information technology to reduce burden?
The forms are available from the Bureau of the Fiscal Service and also on the Internet as a fill-in PDF form, but only paper forms may accepted in this process.
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.
The information is collected for a single purpose when it is necessary for an individual to substantiate in writing why they cannot receive payment by EFT. No other federal governmental agency collects this type of information, therefore, no duplication exists.
If the collection of information impacts small businesses or other small entities (Item 5 of OMB Form 83-I), describe any methods used to minimize burden.
Only individuals may request a waiver and therefore the collection of information applies only to individuals, not to small businesses or other small entities.
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.
Failure to collect this information would violate the requirements of 31 CFR Part 208 and prevent individuals from exercising their right under the regulation to obtain a waiver from the EFT requirement.
Is this collection of information conducted in a manner consistent with the guidelines of 5 CFR 1320.6?
There are no special circumstances. The collection of information cannot be conducted less frequently because the collection is initiated for a single purpose.
What effort was made to notify the general public about this collection of information?
The Bureau published a 60-day notice in the Federal Register on April 15, 2015, Volume 80, Page 20292 to solicit comments from the public on the extension of this collection of information; no comments were received.
Explain any decision to provide any payment or gift to respondents, other than reenumeration of contractors or grantees.
There are no payments or gifts made to respondents.
Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulation, or agency policy.
Aside from protections contained in the Privacy Act, there is no guarantee of confidentiality.
A privacy impact assessment (PIA) has been conducted for information collected under this request as part of the “Direct Deposit Enrollment Records” system and a Privacy Act System of Records notice (SORN) has been issued for this system under FMS .006. The Department of Treasury PIAs can be found at http://www.treasury.gov/privacy/PIAs/Pages/default.aspx
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.
Individuals requesting a waiver from the EFT requirement due to a mental impairment must explain how the mental impairment necessitates receipt of their payments by paper check. This information will only be used to validate that a waiver is necessary and the information will not be disclosed to any other parties.
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.
It is estimated that 3,250 recipients will apply for a waiver from the EFT requirement. They will only need to complete the waiver response one time, unless the form is incomplete and has to be returned to the recipient. The estimated annual burden hours are 1,083 (20 minutes per form).
|
# Respondents |
# Responses Per Respondent |
Annual Responses |
Hours Per Response |
Total Burden |
1201W |
2,790 |
1 |
2,790 |
.33 |
930 |
1201W (SP) |
210 |
1 |
210 |
.33 |
70 |
1201W-DFAS |
250 |
1 |
250 |
.33 |
82.5 |
TOTAL |
3,250 |
1 |
3,250 |
.33 |
1,082.5 |
Provide an estimate for the total annual cost burden to respondents or recordkeepers resulting from the collection of information.
It will cost the recipients $1,593 in postage ($.49 each) to mail the completed forms to the waiver center in Dallas.
Provide estimates of annualized costs to the Federal government.
The costs to administer the waiver process are included in Treasury’s overall reimbursement to the Federal Reserve Bank as a fiscal agent to operate the Go Direct program is $1, 593 in postage.
Explain the reasons for any program changes or adjustments.
No changes or adjustments are reported for this renewal.
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.
The results of the collection of this information will not be published for statistical use.
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 are seeking approval not to display the expiration date of the OMB approval. Identifying this date may cause confusion with the respondent on when form must be submitted to the bureau for consideration; as well as multiple printings of the form may reflect conflicting dates if older stock is retained for distribution.
Explain each exception to the certification statement.
There are no exceptions to the certification statement.
B. Collections of Information Employing Statistical Methods
No statistical methods are being employed for this collection of information.
| File Type | application/msword |
| File Title | SUPPORTING STATEMENT |
| Author | cbrice |
| Last Modified By | Bruce Sharp |
| File Modified | 2015-07-21 |
| File Created | 2014-06-03 |