Supporting Statement - 0013(revised)

Supporting Statement for Form SSA-8-F4,

Application For Lump-Sum Death Payment

20 CFR 404.390-404.392

OMB No. 0960-0013

A. Justification

1. Introduction/Authoring Laws and Regulations

Title II of the Social Security Act (the Act) provides for payment of a lump-sum death payment (not to exceed $255) upon the death of an insured individual. Section 202(i) of the Act explains the conditions of eligibility for this payment, including the filing of an application. Regulations at 20 CFR 404.390-404.392 of the Code of Federal Regulations set the procedures and policies for implementing Section 202(i) of the Act. 20 CFR 404.392 requires the filing of an application by individual applicants to collect the information needed to determine eligibility for the payment. The

SSA-8-F4 elicits the information about the applicant and the relationship to the deceased needed to make this determination of eligibility.

2. Description of Collection

SSA uses Form SSA-8-F4 to collect information needed to authorize payment of the lump-sum death payment (LSDP) to a widow, widower, or children as defined in Section 202(i) of the Act. Respondents complete the application for this one-time payment via paper form, telephone, or during an in-person interview with SSA employees. Respondents are applicants for the LSDP.

3. Use of Information Technology to Collect the Information

In accordance with the agency’s Government Paperwork Elimination Act plan, SSA created an Intranet version of Form SSA-8-F4. Based on our data, we estimate approximately 95% of respondents under this OMB number use the electronic version.

4. Why We Cannot Use Duplicate Information

The nature of the information we are collecting and the manner in which we are collecting it preclude duplication. SSA does not use another collection instrument to obtain similar data.

5. Minimizing Burden on Small Respondents

This collection does not significantly affect small businesses or other small entities.

6. Consequence of Not Collecting Information or Collecting it Less Frequently

If we did not use Form SSA-8-F4, we would have no way to determine eligibility for LSDP, and would be unable to authorize payments to the widow, widower, or children of the deceased beneficiary. Because we collect the information on an as needed basis, we cannot collect it less frequently.

There are no technical or legal obstacles that prevent burden reduction.

7. Special Circumstances

There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.

8. Solicitation of Public Comment and Other Consultations with the Public

The 60-day advance Federal Register Notice published on April 9, 2013, at

78 FR 21181, and we received no public comments. The 30-day FRN published on June 28, 2013 at 78 FR 39055. If we receive any comments in response to this Notice, we will forward them to OMB

9. Payment or Gifts to Respondents

SSA does not provide payments or gifts to the respondents.

10. Assurances of Confidentiality

SSA protects and holds confidential the information it collects in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974), and OMB Circular No. A-130.

11. Justification for Sensitive Questions

The information collection does not contain any questions of a sensitive nature.

12. Estimates of Public Reporting Burden

Modality of Completion	Number of Respondents	Frequency of Response	Average Burden Per Response (minutes)	Estimated Total Annual Burden (hours)
MCS	557,650	1	9	83,648
Paper	29,350	1	10	4,892
Total	587,000			88,540

The total burden for this ICR is 93,187 hours. This figure represents burden hours, and we did not calculate a separate cost burden.

13. Annual Cost Burden to the Respondents (Other)

The collection does not impose a known cost burden to the respondents.

14. Annual Cost To Federal Government

The annual cost to the Federal government is approximately $89,841. This estimate is a projection of printing and distribution costs for the information collection, and for collecting the information.

15. Program Changes or Adjustments to the Information Collection Request

There has been a change in the public reporting burden, because we are combining the MCS/signature proxy collections, and each method had a different response time by a minute, which changed the reported burden hours. We no longer require signature proxy, because MCS are done through signature proxy attestation, unless the applicant prefers to provide a wet signature, therefore, we are combining the MCS/signature proxy collections.

16. Plans for Publication Information Collection Results

SSA will not publish the results of the information collection.

17. Displaying the OMB Approval Expiration Date

OMB granted SSA an exemption from the requirement to print the OMB expiration date on its program forms. SSA produces millions of public-use forms with life cycles exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public-use forms, (e.g., on an annual basis), OMB granted this exemption so SSA would not have to destroy stocks of otherwise usable forms with expired OMB approval dates, avoiding Government waste.

18. Exception to Certification Statement

SSA is not requesting an exception to the certification requirements at 5 CFR

1320.9 and related provisions at 5 CFR 1320.8(b)(3).

B. Collection of Information Employing Statistical Methods

SSA does not use statistical methods for this information collection.