Private Printing and Modification of Prescribed Application and Other Forms

Forms and Documents

Document Name	Status
Supporting Statement - 0663.docx Supporting Statement A	2016-10-28

IC Document Collections

IC ID	Document Title	Status
9711	Private Printing and Modification of Prescribed Application and Other Forms	Modified

ICR Details

OMB Control No: 0960-0663	ICR Reference No: 201607-0960-012
Status: Historical Active	Previous ICR Reference No: 201309-0960-003
Agency/Subagency: SSA	Agency Tracking No:
Title: Private Printing and Modification of Prescribed Application and Other Forms
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: 12/12/2016
	Date Received in OIRA: 10/28/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2019	36 Months From Approved	01/31/2017
Responses	150	0	225
Time Burden (Hours)	25	0	30
Cost Burden (Dollars)	0	0	0

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Abstract: Regulation 20 CFR 422.527 states that any person, institution, or organization wishing to privately reproduce, duplicate, or print any of SSA's applications (such as forms) must first obtain written approval from SSA to do so. The respondents are persons or organizations wishing to privately reproduce or print any of SSA's applications.

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Authorizing Statute(s): US Code: 42 USC 1320b¿10 Name of Law: Social Security Act
  

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:
	81 FR 51957	08/05/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 73189	10/24/2016
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
Private Printing and Modification of Prescribed Application and Other Forms

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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	150	225	0	-75	0	0
Annual Time Burden (Hours)	25	30	0	-5	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The burden decrease is due to fewer companies providing SSA forms to their clients in a way that requires review by SSA, as well as regulations put in place around the time of the previous OMB review becoming standard practice.

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Annual Cost to Federal Government: $897

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]? 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

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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: 10/28/2016

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