Supporting Statement - 0293

Supporting Statement for Form SSA‑4641‑F4

Authorization for the Social Security Administration to Obtain

Account Records from a Financial Institution

20 CFR 416.200 & 416.203

OMB No. 0960-0293

A. Justification

1. Introduction/Authoring Laws and Regulations

Sections 1631(e)(1) of the Social Security Act (Act), 20 CFR 416.200 and

20 CFR 416.203 of the Code of Federal Regulations authorize the Social Security Administration (SSA) to collect and verify information on applications for the Supplemental Security Income (SSI) program. Form SSA-4641-F4 complies with the authorization and certification requirements of the Right to Financial Privacy Act of 1978 (12 USC 35, Sections 3402-3404), which specifies conditions which we must meet before SSA can disclose the account records of financial institutions with customer authorization.

2. Description of Collection

SSA collects and verifies financial information from individuals applying for Title II and Title XVI waiver determinations, as well as those who apply for, or currently receive (in the case of redetermination) Supplemental Security Income (SSI) payments. We require the financial information from these applicants to: (1) determine the eligibility of the applicant or recipient for Supplemental Security Income (SSI) benefits; or (2) determine if a request to waive a Social Security overpayment defeats the purpose of the Social Security Act. If the Title II and Title XVI waiver applicants, or the SSI claimants provide incomplete, unavailable, or seemingly altered records, SSA contacts their financial institutions to verify the existence, ownership, and value of accounts owned. Financial institutions need individuals to sign Form SSA-4641-F4, or contact SSA and use the Internet version, e4641, to authorize the individual’s financial institutions to disclose records to SSA. The respondents are Title II and Title XVI recipients applying for waivers, or SSI applicants, recipients, and their deemors to determine SSI eligibility.

2. Use of Information Technology to Collect the Information

SSA uses an electronic-based financial account verification system for those requiring a wet signature to release financial account information. Our AFI System includes screens, which allow us to electronically record information, then print out the documentation for signature, if needed (in cases where we cannot use verbal attestation in place of a wet signature). SSA also uses a paper Form SSA‑4641-F4 for those financial institutions that do not have the capability to respond electronically. In accordance with the agency’s Government Paperwork Elimination Act plan, SSA created an Internet version of Form SSA-4641-F4, the e4641. Based on our data, we estimate approximately 99% of respondents under this OMB number use the electronic version.

2. Why We Cannot Use Duplicate Information

The nature of the information we collect and the manner in which we collect it precludes duplication. SSA does not use another collection instrument to obtain similar data.

5. Minimizing Burden on Small Respondents

This collection does not significantly affect small businesses or other small entities.

6. Consequence of Not Collecting Information or Collecting it Less Frequently

If we did not use Form SSA-4641-F4, or the Internet e4641, individuals who are unable to secure necessary evidence on their own (due to physical, mental, or financial limitations) could be disadvantaged, and it would create a high risk of incorrect eligibility determinations and incorrect payment of benefits. Since we only collect this information as necessary, we cannot collect it less frequently. There are no technical or legal obstacles to burden reduction.

7. Special Circumstances

There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.

8. Solicitation of Public Comment and Other Consultations with the Public

The 60-day advance Federal Register Notice published on July 23, 2015, at 80 FR 43828, and we received no public comments. SSA published the second Notice on February 8, 2016, at 81 FR 6586. If we receive comments in response to the 30‑day Notice, we will forward them to OMB. We did not consult with the public in the revision of this form.

8. Payment or Gifts to Respondents

We provide payments to the respondents who are financial institutions to compensate them for the time it takes to respond to our request. SSA pays the respondents at a rate determined by the Federal Reserve Board in accordance with the Right to Financial Privacy Act of 1978.

8. Assurances of Confidentiality

SSA protects and holds confidential the information it collects in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974), and OMB Circular No. A-130.

8. Justification for Sensitive Questions

The information collection does not contain any questions of a sensitive nature.

8. Estimates of Public Reporting Burden

Since we estimate different response times per modality (paper or Internet), the chart below shows the burden for this information collection:

Modality of Completion	Number of Respondents	Frequency of Response	Average Burden Per Response (minutes)	Estimated Total Annual Burden (hours)
SSA-4641 (paper)	252,500	1	6	25,250
e4641 and AFI (Internet)	15,747,500	1	2	524,917
Totals	16,000,000			550,167

The total burden for this ICR is 550,167 hours. This figure represents burden hours, and we did not calculate a separate cost burden.

13. Annual Cost to the Respondents (Other)

This collection does not impose a known cost burden on the respondents.

14. Annual Cost To Federal Government

The annual cost to the Federal Government is approximately $11,820,128. This estimate is a projection of the costs for distributing the collection instrument and for collecting the information.

15. Program Changes or Adjustments to the Information Collection Request

The burden increase stems from a change in the ratio between the paper and Internet modalities. We increased the number of paper forms to reflect our refined estimates on the number of paper forms sent via fax and US Mail to financial institutions by SSA field offices and SSA’s contractor. Since it takes longer to respond via paper form, this increased the total annual burden, even though the total number of respondents did not change. As we mention in our Addendum, if we notice a burden change due to the new AFI waiver requirements, we will inform SSA via Change Request.

16. Plans for Publication Information Collection Results

SSA will not publish the results of the information collection.

17. Displaying the OMB Approval Expiration Date

For the paper SSA-4641: OMB granted SSA an exemption from the requirement to print the OMB expiration date on its program forms. SSA produces millions of public-use forms with life cycles exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis), OMB granted this exemption so SSA would not have to destroy stocks of otherwise useable forms with expired OMB approval dates, avoiding Government waste.

For the electronic e4641, and AFI System: SSA is not requesting an exception to the requirement to display an expiration date.

18. Exceptions to Certification Statement

SSA is not requesting an exception to the certification requirements at 5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b)(3).

B. Collections of Information Employing Statistical Methods

SSA does not use statistical methods for this information collection.