Request for Reinstatement (Title XVI)

Forms and Documents

Document Name	Status
Form SSA-372 Request for Reinstatement (Title XVI) Form	Modified
Supporting Statement - 0744.doc Supporting Statement A	2009-12-10
Addendum - 0744.doc Supplementary Document	2009-11-19

IC Document Collections

IC ID	Document Title	Status
45441	Request for Reinstatement (Title XVI) Form	Modified

ICR Details

OMB Control No: 0960-0744	ICR Reference No: 200909-0960-008
Status: Historical Active	Previous ICR Reference No: 200609-0960-029
Agency/Subagency: SSA	Agency Tracking No:
Title: Request for Reinstatement (Title XVI)
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: 04/02/2010
	Date Received in OIRA: 12/10/2009
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2013	36 Months From Approved	05/31/2010
Responses	2,000	0	2,000
Time Burden (Hours)	67	0	67
Cost Burden (Dollars)	0	0	0

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Abstract: SSA uses the SSA-372 to obtain a signed statement from individuals stating a request for Expedited Reinstatement (EXR) of their Title XVI Supplemental Security Income (SSI) payments, and to prove that the requestor meets the EXR requirements. We maintain the form in the disability folder of the applicant to demonstrate the individual’s awareness of the EXR requirements and their choice to request EXR. Respondents are individuals requesting expedited reinstatement of their Title XVI SSI payments.

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Authorizing Statute(s): PL: Pub.L. 106 - 170 112 Name of Law: Ticket to Work and Work Incentives Improvement Act of 1999
   US Code: 42 USC 1383 Name of Law: null
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 51353	10/06/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 64801	12/08/2009
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Request for Reinstatement (Title XVI)	SSA-372	Request for Reinstatement -- Title XVI

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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	2,000	2,000	0	0	0	0
Annual Time Burden (Hours)	67	67	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:

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Annual Cost to Federal Government: $4,620

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)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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: 12/10/2009

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