Tribal Council Coverage Agreement

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Justification for Non-Substantive Changes - 0812.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2019-11-06	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
235112	Tribal Council Coverage Agreement	Other-Indian Tribal Council Coverage Agreement	Modified

ICR Details

OMB Control No: 0960-0812	ICR Reference No: 201911-0960-002
Status: Active	Previous ICR Reference No: 201812-0960-001
Agency/Subagency: SSA	Agency Tracking No:
Title: Tribal Council Coverage Agreement
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: 11/22/2019
	Date Received in OIRA: 11/06/2019
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2022	05/31/2022	05/31/2022
Responses	100	0	100
Time Burden (Hours)	17	0	17
Cost Burden (Dollars)	0	0	0

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Abstract: SSA will use the Tribal Council Coverage Agreement to collect information if a tribe wishes to obtain Social Security coverage. Each tribe requesting coverage fills out an agreement, and SSA employees collect this information via the paper agreement. The respondents are Indian tribal councils who wish to receive Social Security coverage for their members. We are making non-substantive changes to Form SSA-177 to account for Tribe’s government organizations that do not identify as “tribal council”.

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Authorizing Statute(s): None

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:
	84 FR 371	01/25/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 11625	03/27/2019
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Tribal Council Coverage Agreement

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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	100	100	0	0	0	0
Annual Time Burden (Hours)	17	17	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: This is a new agreement that increases the public reporting burden.

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Annual Cost to Federal Government: $3,624

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.     No

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.     No

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: 11/06/2019

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