Application for Supplemental Security Income (SSI)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-8000-BK Application for Supplemental Security Income--SSA-8000-BK (Paper Form)	Form	Modified	Repair queued
Justification for the Non-Substantive Changes - 0229.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2021-05-07	Repair queued
Supporting Statement - 0229.docx	Supporting Statement A	Uploaded 2021-05-07	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9158	Application for Supplemental Security Income--SSI Claims System/Signature Proxy and Preliminary Claims System (PCS)	Other-Internal Screens	Unchanged
44924	Application for Supplemental Security Income--SSA-8000-BK (Paper Form)	Form	Modified

ICR Details

OMB Control No: 0960-0229	ICR Reference No: 202105-0960-005
Status: Received in OIRA	Previous ICR Reference No: 201907-0960-001
Agency/Subagency: SSA	Agency Tracking No:
Title: Application for Supplemental Security Income (SSI)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 05/07/2021

table that charts list comparision

	Requested	Previously Approved
Expiration Date	12/31/2021	12/31/2021
Responses	1,233,453	1,233,453
Time Burden (Hours)	721,609	721,609
Cost Burden (Dollars)	0	0

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Abstract: The SSI program provides aged, blind, and disabled individuals who have little or no income with funds for food, clothing, and shelter. There are two ways respondents can apply for SSI. Individuals may obtain and complete the SSA-8000-BK application paper form, or via personal interview, during which the SSA employee will enter the applicant’s data directly into the SSI Claims System. SSA uses the information gathered to: (1) determine whether claimants meet all statutory and regulatory requirements for SSI eligibility; and (2) calculate SSI payment amounts. The respondents are SSI applicants or their authorized representative. This is a non-substantive Change Request to convert the form to a standard, fillable PDF (fillable, printable).

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Authorizing Statute(s): US Code: 42 USC 1383 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:
	83 FR 38441	08/06/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 52042	10/15/2018
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Application for Supplemental Security Income--SSA-8000-BK (Paper Form)	SSA-8000-BK	Application for Supplemental Security Income (SSI)
Application for Supplemental Security Income--SSI Claims System/Signature Proxy and Preliminary Claims System (PCS)

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ICR Summary of Burden

table that charts list of burden

	Total Request	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	1,233,453	1,233,453	0	0	0	0
Annual Time Burden (Hours)	721,609	721,609	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:

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Annual Cost to Federal Government: $13,587,885

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: 05/07/2021

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