View Information Collection Request (ICR) Package
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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0960-0546
ICR Reference No:
201703-0960-019
Status:
Historical Active
Previous ICR Reference No:
201406-0960-004
Agency/Subagency:
SSA
Agency Tracking No:
Title:
SSI Notice of Interim Assistance Reimbursement (IAR)
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
10/27/2017
Retrieve Notice of Action (NOA)
Date Received in OIRA:
08/04/2017
Terms of Clearance:
In accordance with 5 CFR 1320, the information collection is approved for three years.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
10/31/2020
36 Months From Approved
10/31/2017
Responses
637,160
0
637,160
Time Burden (Hours)
45,216
0
45,216
Cost Burden (Dollars)
0
0
0
Abstract:
Section 1631(g) of the Act authorizes SSA to reimburse an IAR agency from an individual's retroactive Supplemental Security Income (SSI) payment for assistance the IAR agency gave the individual for meeting basic needs while an SSI claim was pending or SSI payments were suspended or terminated. The State or local agency needs an IAR agreement with SSA to participate in the IAR program. The individual receiving the IAR payment signs an authorization form with an IAR agency to allow SSA to repay the IAR agency for funds paid in advance prior to SSA's determination on the individual's claim. The authorization represents the individual's intent to file for SSI, if they did not file an application prior to SSA receiving the authorization. Agencies who wish to enter into an IAR agreement with SSA needs to meet the following requirements: (a) Reporting Requirements - Each IAR agency agrees to: (1) Notify SSA of receipt of an authorization for initial claims or cases they are appealing, and submit a copy of that authorization either through a manual or electronic process; (2) inform SSA of the amount of reimbursement; (3) submit a written request for dispute resolution on a determination; (4) notify SSA of interim assistance paid (using the SSA–L8125–F6); (5) inform SSA of any deceased claimants who participate in the IAR program and ; (6) review and sign an agreement with SSA. (b) Recordkeeping Requirements - The IAR agencies agree to retain all notices, agreement, authorizations, and accounting forms for the period defined in the IAR agreement for the purposes of SSA verifying transactions covered under the agreement. (c) Third Party Disclosure Requirements: Each participating IAR agency agrees to send written notices from the IAR agency to the recipient regarding payment amounts and appeal rights. (d) Periodic Review of Agency Accounting Process - The IAR agency makes the IAR accounting records of paid cases available for SSA review and verification. SSA conducts reviews either onsite or through the mail of the authorization forms, notices to the claimant and accounting forms. Upon completion of the review, SSA provides a written report of findings to the IAR agency director. The respondents are State IAR officers.
Authorizing Statute(s):
None
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
82 FR 21291
05/05/2017
30-day Notice:
Federal Register Citation:
Citation Date:
82 FR 35022
07/27/2017
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
13
IC Title
Form No.
Form Name
a) State Notification of Receipt of Authorization (Electronic Process)
b) State Submission of Copy of Authorization (Manual Process)
c) State Notification to SSA of Amount of Reimbursement
d) State Request for Determination--Dispute Resolution
e) Paper Form SSA-L8125-F6
SSA-L8125-F6
Supplemental Security Income Notice of Interim Assistance Reimbursement
f) State Notification to SSA of Deceased Claimant
g) Review/Signing Agreements
h) Maintenance of Authorization Forms
i) Maintenance of Accounting Forms and Notices
j) Written Notice from State to Recipient Regarding Amount of Payment
k) Retrieve and Consolidate Authorization and Accounting Forms
l) Participate in Periodic Review
m) Correct Administrative and Accounting Discrepancies
ICR Summary 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
637,160
637,160
0
0
0
0
Annual Time Burden (Hours)
45,216
45,216
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:
Annual Cost to Federal Government:
$0
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?
Uncollected
Agency Contact:
Faye Lipsky 410 965-8783 faye.lipsky@ssa.gov
Common Form ICR:
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:
(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:
08/04/2017
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