Important Information About Your Appeal, Waiver Rights and Repayment Options

ICR 202108-0960-002

OMB: 0960-0779

Federal Form Document

Forms and Documents
ICR Details
0960-0779 202108-0960-002
Received in OIRA 201807-0960-017
Important Information About Your Appeal, Waiver Rights and Repayment Options
Revision of a currently approved collection   No
Regular 01/13/2022
  Requested Previously Approved
36 Months From Approved 02/28/2022
666,666 700,000
500,000 175,000
0 0

This collection is a voluntary, one-time collection, for the respondents to let SSA know that they want to request a lower rate of benefit withholding, installment payments, an explanation of the overpayment, an appeal, or a waiver. Respondents can complete the form and return it to an SSA office, or they may also contact SSA via telephone or via an in-office visit. The respondent is not required to complete this form; however, they may complete this form alone or with help. The respondents are individuals who are overpaid Social Security payments.

US Code: 42 USC 404 Name of Law: Social Security

Not associated with rulemaking

  86 FR 56746 10/12/2021
87 FR 139 01/03/2022

  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 666,666 700,000 0 0 -33,334 0
Annual Time Burden (Hours) 500,000 175,000 0 0 325,000 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
When we last cleared this IC in 2019, the burden was 175,000 hours. However, we are currently reporting a burden of 166,667 hours. This change stems from a decrease in the number of responses from 700,000 to 666,666. Although the number of responses changed, SSA did not take any actions to cause this change. These figures represent current Management Information data. In addition, as per OMB’s request, SSA is including the 30-minute travel time to a field office in our burden calculations, which increases the overall burden for this collection.

Faye Lipsky 410 965-8783 [email protected]


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:
    (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;
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.

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