Request for Workers’ Compensation/Public Disability Benefit Information
20 CFR 404.408(e)
OMB No. 0960-0098
Justification
Introduction/Authoring Laws and Regulations
Section 224 of the Social Security Act provides for an offset (reduction) of Social Security Disability Insurance benefits (SSDI) when disabled workers also receive Workers' Compensation (WC) or Public Disability benefits (PDB). 20 CFR 404.408(e) of the Code of Federal Regulations states that individual(s) may need to furnish evidence for the WC/PDB benefits they receive. If the disabled workers are unable to provide evidence verifying the amount of WC/PDB paid, the Social Security Administration (SSA) must obtain such information from the Federal, State, or local agency; self-insured public or private employer; or insurance carrier administering the WC/PDB.
Description of Collection
Claimants for Social Security disability payments who are also receiving WC/PDB must notify SSA about their WC/PDB, so the agency can consider a possible offset to reduce their Social Security disability payments accordingly. If claimants provide necessary evidence, such as a copy of their award notice, benefit check, etc. that is sufficient verification. In cases where claimants cannot provide such evidence, SSA uses Form SSA-1709 to obtain WC/PDB payment evidence. The entity paying the WC/PDB benefits, its agent (such as insurance carrier), or an administrating public agency completes this form. The respondents are Federal, State, and local agencies; insurance carriers; and public or private self-insured companies administering WC/PDB benefits to disability claimants.
Use of Information Technology to Collect the Information
Form SSA-1709 is available on SSA’s website for the public to print, fill-out, and mail to SSA. SSA then mails the form to the entity (insurance carrier, WC Board, etc.) for completion of all information about WC/PDB benefit payment. The entity then signs and dates the form and returns the Form SSA-1709 to SSA. SSA did not create an electronic version of Form SSA-1709 under the agency’s Government Paperwork Elimination Act, as we require a wet signature, authorizing release of the WC/PDB information.
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.
Minimizing Burden on Small Respondents
This collection does not significantly affect a substantial number of small businesses or other small entities.
Consequence of Not Collecting Information or Collecting it Less Frequently
If we did not use Form SSA-1709, we administer incorrect payments. Because we collect the information on an as needed basis, we cannot collect it less frequently. There are no technical or legal obstacles to burden reduction.
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.
Solicitation of Public Comment and Other Consultations with the Public
The 60-day advance Federal Register Notice published on March 21, 2018, at
83 FR 12455, and we received no public comments. The 30-day FRN published on June 8, 2018 at 83 FR. If we receive any comments in response to this Notice, we will forward them to OMB. We did not consult with the public in the revision of this form.
Payment or Gifts to Respondents
SSA provides no payment or gifts to the respondents.
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.
Justification for Sensitive Questions
The information collection does not contain any questions of a sensitive nature.
Estimates of Public Reporting Burden
Modality of Completion |
Number of Respondents |
Frequency of Response |
Average Burden Per Response (minutes) |
Total Estimated Annual Burden (hours) |
SSA-1709 |
120,000 |
1 |
15 |
30,000 |
The total burden for this ICR is 30,000 hours. We based these figures on current management data. This figure represents burden hours, and we did not calculate a separate cost burden.
Annual Cost to the Respondents (Other)
This collection does not impose a known cost burden on the respondents.
Annual Cost To Federal Government
The annual cost to the Federal Government is approximately $600,000. This estimate accounts for costs from the following areas: (1) designing, printing, and distributing the form; and (2) SSA employee (e.g., field office, 800 number, DDS staff) information collection and processing time.
Program Changes or Adjustments to the Information Collection Request
There are no changes in the public reporting burden.
Plans for Publication Information Collection Results
SSA will not publish the results of the information collection.
Displaying the OMB Approval Expiration Date
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.
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).
Collections of Information Employing Statistical Methods
SSA does not use statistical methods for this collection.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Sipple, Naomi |
| File Modified | 0000-00-00 |
| File Created | 2021-01-21 |