Statutory Benefit Continuation Election Statement

ICR 202410-0960-021

OMB:

Federal Form Document

ICR Details
202410-0960-021
Received in OIRA
SSA
Statutory Benefit Continuation Election Statement
New collection (Request for a new OMB Control Number)   No
Regular 10/25/2024
  Requested Previously Approved
36 Months From Approved
77,145 0
120,861 0
0 0

Under current policy, the individual records their request on the form SSA-795, Statement of Claimant or Other Person (OMB 0960-0045). When the individual submits a writing of their own, the written statement often does not include all the necessary information. Field office staff must often contact the individual to explain the available options. In addition, the individual has 15 calendar days from the notice date to submit their election to continue benefits, which often results in the individual having to visit the local field office in person to meet the deadline. SSA will use the Statutory Benefit Continuation Election Statement, Form SSA-792 to standardize our collection of an individual’s benefit continuation election choice. This new information collection allows the individual to elect from a variety of options available to them for continued disability benefits and Medicare coverage.

None
None

Not associated with rulemaking

  89 FR 67141 08/19/2024
89 FR 84431 10/22/2024
No

  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 77,145 0 0 77,145 0 0
Annual Time Burden (Hours) 120,861 0 0 120,861 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
This is a new form that increases the public reporting burden. See question #12 for updated burden figures. * Note: The total burden reflected in ROCIS is 120,861, while the burden cited in #12 of the Supporting Statement is 51,430. This discrepancy is because the ROCIS burden reflects the following components: field office waiting time + a rough estimate of a 30-minute, one-way, drive burden + learning costs. In contrast, the chart in #12 of the Supporting Statement reflects actual burden.

$952,900
No
    Yes
    Yes
No
No
No
No
Faye Lipsky 410 965-8783 [email protected]

  No

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.
10/25/2024


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