View Information Collection Request (ICR) Package

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: 0960-0766	ICR Reference No: 201908-0960-007
Status: Historical Active	Previous ICR Reference No: 201607-0960-016
Agency/Subagency: SSA	Agency Tracking No:
Title: Request for Proof(s) from Custodian of Records
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: 04/14/2020
	Date Received in OIRA: 01/13/2020
Terms of Clearance: Current agency guidance restricts personnel from sending this form to respondents electronically. One year prior to resubmission, the agency will brief OMB on potential opportunities to changes in GN 00301.195 or other parts of SSA guidance/regulations that would facilitate electronic correspondence when appropriate.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2023	36 Months From Approved	04/30/2020
Responses	118	0	600
Time Burden (Hours)	20	0	101
Cost Burden (Dollars)	0	0	0

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	118	600	-482
Annual Time Burden (Hours)	20	101	-81
Annual Cost Burden (Dollars)	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 2016, the burden was 101 hours. However, we are currently reporting a burden of 20 hours. This change stems from a decrease in the number of responses from 600 to 118. This change also stems from a decrease in the number respondents who need help obtaining evidence of death, marriage, or divorce in connection with claims for benefits. Although the number of responses changed, SSA did not take any actions to cause this change.

Annual Cost to Federal Government: $413

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

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