Statement of Employer

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-7011-F4 Statement of Employer	Form and Instruction	Modified	Available
Form SSA-7011-F4 Statement of Employer	Form and Instruction	Modified	Repair queued
Addendum - 0030 (Final).docx	Supplementary Document	Uploaded 2021-09-03	Repair queued
Supporting Statement - 0030 (Final).docx	Supporting Statement A	Uploaded 2021-09-10	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
43689	Statement of Employer	Form and Instruction	Modified	Statement of Employer
43689	Statement of Employer	Form and Instruction	Modified
43689	Statement of Employer	Other-Revised PA and PRA Statements	Modified

ICR Details

OMB Control No: 0960-0030	ICR Reference No: 202104-0960-013
Status: Historical Active	Previous ICR Reference No: 201806-0960-006
Agency/Subagency: SSA	Agency Tracking No:
Title: Statement of 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: 07/28/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/10/2021
Terms of Clearance: The agency provided additional description of the information collection and modified its burden estimate.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2025	36 Months From Approved	07/31/2022
Responses	500	0	500
Time Burden (Hours)	500	0	167
Cost Burden (Dollars)	0	0	0

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Abstract: When workers report they were paid wages, but cannot provide proof of those earnings, and the wages do not appear in SSA’s records of earnings, SSA uses Form SSA-7011-F4 to document the alleged wages. Specifically, the agency uses the form to resolve discrepancies in the individual’s Social Security earnings record, and to process claims for Social Security benefits. We only send Form SSA-7011-F4 to employers if we are unable able to locate the earnings information within our own records. The respondents are employers who can verify wage allegations made by wage earners.

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Authorizing Statute(s): US Code: 42 USC 405 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:
	86 FR 35371	07/02/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 49403	09/02/2021
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
Statement of Employer	SSA-7011-F4	Statement of 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	500	500	0	0	0	0
Annual Time Burden (Hours)	500	167	0	0	333	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 2018, the burden was 167 hours. However, we are currently reporting a burden of 500 hours. This change stems from an increase in the completion time from 20 minutes to 60 minutes. After review of our burden estimate, we determined that 60 minutes more accurately represents completion time and is supported by current Management Information data.

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Annual Cost to Federal Government: $11,120

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? 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: 09/10/2021

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