Claim for Amounts Due in the Case of a Deceased Beneficiary

Forms and Documents

Document	Type	Status	Availability
Form SSA-1724-F4 Claim for Amounts Due in the Case of a Deceased Beneficiary	Form and Instruction	Modified	Repair queued
Addendum 0101.doc	Supplementary Document	Uploaded 2018-02-07	Repair queued
0960-0101 Supporting Statement.doc	Supporting Statement A	Uploaded 2018-04-10	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
43696	Claim for Amounts Due in the Case of a Deceased Beneficiary	Form and Instruction	Modified

ICR Details

OMB Control No: 0960-0101	ICR Reference No: 201712-0960-005
Status: Active	Previous ICR Reference No: 201511-0960-011
Agency/Subagency: SSA	Agency Tracking No:
Title: Claim for Amounts Due in the Case of a Deceased Beneficiary
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/03/2018
	Date Received in OIRA: 05/10/2018
Terms of Clearance: In accordance with 5 CFR 1320, the information collection is approved for three years.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2021	36 Months From Approved	08/31/2018
Responses	250,000	0	250,000
Time Burden (Hours)	41,667	0	41,667
Cost Burden (Dollars)	0	0	0

---

Abstract: SSA requests applicants complete Form SSA-1724 when there is insufficient information in the file to identify the person(s) entitled to the underpayment, or the person's address. SSA collects the information when a surviving widow(er) is not already entitled to a monthly benefit on the same earnings records, or is not filing for a lump-sum death payment as a former spouse. SSA uses the information Form SSA-1724 provides to ensure proper payment of an underpayment due a deceased beneficiary. The respondents are applicants for underpayments owed to deceased beneficiaries. We are making non-substantive changes so that we can use the form for both Title II underpayments and Title XVIII Medicare premium refunds.

---

Authorizing Statute(s): US Code: 42 USC 404 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 1651	01/12/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 14306	04/03/2018
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Claim for Amounts Due in the Case of a Deceased Beneficiary	SSA-1724-F4	Claim for Amounts Due In The Case of a Deceased Beneficiary

---

ICR Summary 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	250,000	250,000	0	0	0	0
Annual Time Burden (Hours)	41,667	41,667	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:

---

Annual Cost to Federal Government: $860,000

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

---

Common Form ICR:  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:

(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: 05/10/2018

---