Statement of Income and Resources

ICR 201702-0960-003

OMB: 0960-0124

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Supporting Statement A
2017-05-08
Supplementary Document
2017-05-08
IC Document Collections
IC ID
Document
Title
Status
9097 Modified
ICR Details
0960-0124 201702-0960-003
Active 201403-0960-009
SSA
Statement of Income and Resources
Revision of a currently approved collection   No
Regular
Approved without change 12/13/2017
Retrieve Notice of Action (NOA) 05/17/2017
In accordance with 5 CFR 1320, the information collection is approved for three years.
  Inventory as of this Action Requested Previously Approved
12/31/2020 36 Months From Approved 12/31/2017
341,000 0 341,000
147,767 0 147,767
0 0 0

SSA uses Form SSA-8010-BK to collect income and resources information in Supplemental Security Income (SSI) claims and redeterminations. SSA uses the information to make initial or continuing eligibility determinations for SSI claimants/recipients who are subject to deeming. The respondents are persons whose income and resources SSA considers deemed to applicants or recipients of SSI payments.

US Code: 42 USC 1382a-1382c Name of Law: Social Security Act
   US Code: 42 USC 1382 Name of Law: Social Security Act
   US Code: 42 USC 1382j Name of Law: Social Security Act
   US Code: 42 USC 1383 Name of Law: Social Security Act
  
None

Not associated with rulemaking

  82 FR 12159 02/28/2017
82 FR 21291 05/05/2017
No

1
IC Title Form No. Form Name
Statement of Income and Resources SSA-8010, SSA-8010-BK Statement of Income and Resources (MSSICS Screens) ,   Statement of Income and Resources

  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 341,000 341,000 0 0 0 0
Annual Time Burden (Hours) 147,767 147,767 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$677,431
No
    Yes
    Yes
No
No
No
Uncollected
Faye Lipsky 410 965-8783 faye.lipsky@ssa.gov

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
05/17/2017


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