Application for Supplemental Security Income (SSI)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-8000 Application for Supplemental Security Income--MISSICS/Signature Proxy	Form	Unchanged	Available
Form SSA-8000-BK Application for Supplemental Security Income--Paper Version	Form	Modified	Available
Justification for the Non-Substantive Changes - 0229.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2017-03-27	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9158	Application for Supplemental Security Income--MISSICS/Signature Proxy	Form	Unchanged
44924	Application for Supplemental Security Income--Paper Version	Form	Modified

ICR Details

OMB Control No: 0960-0229	ICR Reference No: 201703-0960-018
Status: Historical Active	Previous ICR Reference No: 201604-0960-009
Agency/Subagency: SSA	Agency Tracking No:
Title: Application for Supplemental Security Income (SSI)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/12/2017
	Date Received in OIRA: 03/27/2017
Terms of Clearance: In accordance with 5 CFR 1320, the information collection is approved for three years.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2019	10/31/2019	10/31/2019
Responses	1,390,942	0	1,390,942
Time Burden (Hours)	813,137	0	813,137
Cost Burden (Dollars)	0	0	0

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Abstract: The SSI program provides aged, blind, and disabled individuals who have little or no income with funds for food, clothing, and shelter. Individuals either complete Form SSA-8000-BK using the paper form, or via personal interview with a claims representative using the electronic Modernized SSI Claims System (MSSICS) to apply for SSI. SSA uses the information gathered from the SSA 8000-BK to: (1) determine whether claimants meet all statutory and regulatory requirements for SSI eligibility; and (2) calculate SSI payment amounts. The respondents are SSI applicants or their representative payees. We are making a Non-Substantive change to renumber questions 20-65 and the Go to #’s on the SSA-8000-BK, due to the removal of Question #19.

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Authorizing Statute(s): US Code: 42 USC 1383 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 31999	05/20/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 51957	08/05/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Application for Supplemental Security Income--Paper Version	SSA-8000-BK	Application for Supplemental Security Income (Revised)
Application for Supplemental Security Income--MISSICS/Signature Proxy	SSA-8000, SSA-8000	Application for Supplemental Security Income (SSI) ,   Application for Supplemental Security Income (SSI)--New Screen for Direct Express

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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	1,390,942	1,390,942	0	0	0	0
Annual Time Burden (Hours)	813,137	813,137	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The decrease in burden hours is due to a decrease in the use of the paper application, as we are entering more applications directly into MSSICS.

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Annual Cost to Federal Government: $352,856

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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

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Common Form ICR:  No

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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: 03/27/2017

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