Addendum to the Supporting Statement for 0960-0293

Addendum to the 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

Revisions to the Collection Instrument

On November 2, 2015, the President signed into law H.R. 1314 (Bipartisan Budget Act of 2015). Section 834 of the Bipartisan Budget Act, “Access to Financial Information (AFI) for Waivers and Adjustments of Recovery,” requires the Commissioner to obtain a claimant’s authorization to obtain financial institution records before waiving overpayment recovery under the “defeats the purpose” provision. The Bipartisan Budget Act included a stipulation in Section 834 requiring SSA to implement this new AFI requirement on February 2, 2016. To that end, we obtained OMB’s approval for the following revisions to the SSA-4641 via Change Request on January 5, 2016:

• Change #1: We added the term “Beneficiary” to the fourth block.

Justification #1: We expanded the use of this form to include Title II beneficiaries, as per the requirement in the Bipartisan Budget Act.

• Change #2: We divided the second section of the form into three parts and added checkboxes.

Justification #2: We want to make a clear distinction between the purpose and scope of the form for Title XVI Supplemental Security Income Eligibility; and Title II and Title XVI waiver determinations.

• Change #3: In the “Request for Records” section, we added 204(b), 1631(b)(1)(B) for Title II. We also made a change beginning with the second sentence to add the following:

“..us either to: (1) determine the eligibility of the applicant or recipient named above 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.”

Justification #3: We expanded the use of this form to include obtaining authorization for waiver determinations for both Title II and Title XVI overpayments.

• Change #4: We updated the Privacy Act Statement.

Justification #4: We expanded the use of this form to include Title II beneficiaries and the current version of this form requires an update to the Privacy Act Statement, per OGC guidance.

In addition to the above revisions, which OMB approved on January 5, 2016, SSA is also making the following revisions to this information collection:

• Change #1: We created the PDF version of this form as promised in our recently approved Change Request.

Justification #1: As per the note we included in the Change Request documentation, we were unable to have the fillable PDF ready for OMB’s review when we submitted the Change Request. We are including the updated fillable version now.

• Change #2: We are adding an extra line to the financial institution address information area at the top of the form for the AFI System, which will shift the form down slightly when printed causing the signature lines to appear on the second page of the form (instead of the first page).

Justification #2: Per our contractor, they are unable to include all of the address information for the financial institutions if they leave the form as it appears in the currently approved PDF. Therefore, they need to add a line to that section of the form, shifting everything down slightly. The information we collect on the AFI System will remain the same, and respondents using the electronic version will not notice any difference until they print the form.

• Change #3: We are including the internal AFI screens for OMB approval.

Justification #3: SSA uses the Access to Financial Institutions (AFI) screens to record financial account information during the interview process; create requests to verify financial accounts; and manage workload listings for the AFI responses. The RFIA AFI screen does not collect new information; it simply replaced the previous method of documenting the claimant, recipient, or deemor’s allegations of resources. The AFI create request screens integrated the e4641 process into the Modernized Supplemental Security Income Claims System. While the public never sees these screens directly, we use them to ensure we record the information electronically.

We use the information related to financial institutions to create and send financial account verification requests to the alleged financial institutions. Once we receive the responses from the financial institutions, we use the AFI Workload Listings to manage the responses that need further development. Sending verification requests and receiving the responses from the financial institutions electronically is part of the AFI implementation plan, which we mentioned in the OMB-approved package from July 25, 2013.

Future Plans

We continue to work with our vendor to update the e4641web application to include the new process for waiver requests for both TII and TXVI. We will submit final versions of the screens for this process as well as any updated burden data (if needed) via the Change Request process when we are ready to implement them.