Request to Resolve Questionable Quarters of Coverage (QC); Request for QC History Based on Relationship

Forms and Documents

Document Name	Status
Form SSA-512 Request to Resolve Questionable Quarters of Coverage (QC) Form	Modified
Form SSA-513 Request for Quarters of Coverage Based on Relationship Form	New
SSA512 and 513 supporting statement.doc Supporting Statement A	0000-00-00

IC Document Collections

IC ID	Document Title	Status
9530	Request to Resolve Questionable Quarters of Coverage (QC) Form	Modified
46506	Request for Quarters of Coverage Based on Relationship Form	New

ICR Details

OMB Control No: 0960-0575	ICR Reference No: 200612-0960-005
Status: Historical Active	Previous ICR Reference No: 200403-0960-001
Agency/Subagency: SSA	Agency Tracking No:
Title: Request to Resolve Questionable Quarters of Coverage (QC); Request for QC History Based on Relationship
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/06/2007
	Date Received in OIRA: 02/26/2007
Terms of Clearance: OMB approves this collection consistent with the e-mail from SSA on 6/4/07. As stated in the e-mail, SSA should correct the form to read "prior to 1978." Currently, the form incorrectly reads "prior to 1798."

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2010	36 Months From Approved	06/30/2007
Responses	550,000	0	550,000
Time Burden (Hours)	18,334	0	18,334
Cost Burden (Dollars)	0	0	0

---

Abstract: Form SSA-512 is used by States to request clarification from SSA on questionable QC information. Form SSA-513 is used by States to request QC information for an alien's spouse or child in cases where an alien does not sign the consent form giving permission to access his/her Social Security records. QC can also be allocated to a spouse and or a child under 18, if needed, to obtain 40 qualifying QC for the alien. The respondents are States agencies that require QC information to determine eligibility for benefits.

---

Authorizing Statute(s): PL: Pub.L. 104 - 193 432 Name of Law: Pesonal Responsibility & Work Opportunity Reconciliation Act of 1996
  

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:
	71 FR 75607	12/15/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 7809	02/20/2007
Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
Request to Resolve Questionable Quarters of Coverage (QC)	SSA-512	Request to Resolve Questionable Quarters of Coverage
Request for Quarters of Coverage Based on Relationship	SSA-513	Request for Quarters of Coverage Based on Relationship

---

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	550,000	550,000	0	0	0	0
Annual Time Burden (Hours)	18,334	18,334	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: $465,850

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

---

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: 02/26/2007

---