Modified Benefit Formula Questionnaire-Employer

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-58 Modified Benefit Formula Questionnaire-Employer	Form	Modified	Available
Supporting Statement -0960- 0477 (Final).docx	Supporting Statement A	Uploaded 2024-03-28	Available
Supporting Statement - 0477.docx	Supporting Statement A	Uploaded 2020-08-07	Repair queued
Addendum 0477.docx	Supplementary Document	Uploaded 2020-08-03	Available
Addendum 0477.docx	Supplementary Document	Uploaded 2020-08-03	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9371	Modified Benefit Formula Questionnaire-Employer	Form	Modified	Modified Benefit Formula Questionnaire-Employer
9371	Modified Benefit Formula Questionnaire-Employer	Other-Privacy Act Statement (revised)	Modified

ICR Details

OMB Control No: 0960-0477	ICR Reference No: 202004-0960-003
Status: Active	Previous ICR Reference No: 201701-0960-016
Agency/Subagency: SSA	Agency Tracking No:
Title: Modified Benefit Formula Questionnaire-Employer
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 07/19/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/07/2020
Terms of Clearance: The agency made modifications to the Supporting Statement to improve clarity and consistency with the Supporting Statement for 0960-0395 (SSA-150). Prior to triannual renewal, the agency will ensure it further updates supporting statement A to explain the distinct uses between this information collection (0960-0477) and 0960-0395.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2027	36 Months From Approved	07/31/2024
Responses	26,925	0	30,000
Time Burden (Hours)	4,488	0	10,000
Cost Burden (Dollars)	0	0	0

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Abstract: SSA collects information on Form SSA-58 to verify the claimant's allegations on Form SSA-150 (OMB#0960-0395, Modified Benefits Formula Questionnaire). SSA uses the SSA-58 to determine if the modified benefit formula is applicable and when to apply it to a person's benefits. SSA sends Form SSA-58 to an employer for pension-related information, if the claimant is unable to provide it. The respondents are employers of people who are eligible after 1985 for both Social Security benefits and a pension based on work not covered by SSA.

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Authorizing Statute(s): US Code: 42 USC 415 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:
	85 FR 26776	05/05/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 45723	07/29/2020
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
Modified Benefit Formula Questionnaire-Employer	SSA-58	Modified Benefit Formula Questionnaire-Employer

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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	26,925	30,000	0	0	-3,075	0
Annual Time Burden (Hours)	4,488	10,000	0	3,142	-8,654	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: When we last cleared this IC in 2017, the burden was 10,000 hours. However, we are currently reporting a burden of 1,346 hours. This change stems from a more accurate calculation of the burden time per response. Although the burden time changed, SSA did not take any actions to cause this change.

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Annual Cost to Federal Government: $48,777

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.     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? No

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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: 08/07/2020

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