Supporting Statement - 0759 (Revised)

Supporting Statement for Form SSA-4111

Certificate of Election for Reduced Widow(er)’s and

Surviving Divorced Spouse’s Benefits

20 CFR 404.335

OMB No. 0960-0759

1. Justification

1. Introduction/Authoring Laws and Regulations

Sections 202(e)(1)(C)(ii)(III) and 202(f)(1)(C)(ii)(III) of the Social Security Act (Act), and 20 CFR 404.335-404.336 of the Code of Federal Regulations, set forth the eligibility criteria and dates for a widow(er) or surviving divorced spouse to file a Certificate of Election for Reduced Widow(er)’s and Surviving Divorced Spouse’s Benefits. Section 202(q) of the Act provides the authority to reduce benefits under certain conditions when a Title II beneficiary elects to receive them. However, we will not pay reduced benefits to already entitled spouses or a divorced spouse for any month before the first month for which they filed a certificate electing reduced benefits, or for any month in which they have a child entitled to child’s insurance benefits on the record of an insured person in their care.

2. Description of Collection

SSA will not pay reduced benefits to an already entitled spouse (or divorced spouse) who:

• Is at least age 62 and under full retirement age in the month of the number holder’s death; and

• Is receiving both reduced spouse’s (or divorced spouse’s) benefits and either retirement or disability benefits in the month before the month of the number holder’s death.

To elect reduced widow(er) benefits, a recipient completes Form SSA-4111. SSA uses the information to pay a qualified dually entitled widow(er) (or surviving divorced spouse) who elects to receive a reduced widow(er) benefit. The respondents are qualified dually entitled widow(er)s (or surviving divorced spouse) who elect to receive a reduced widow(er) benefit.

3. Use of Information Technology to Collect the Information

SSA created a fillable PDF version of Form SSA-4111, which is available on our website. However, due to the low volume of respondents for this form, this form is not a good candidate for electronic implementation.

4. Why We Cannot Use Duplicate Information

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

5. Minimizing Burden on Small Respondents

This collection does not 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-4111, dually entitled widow(er)s or surviving divorced spouses would not receive reduced widow(er) benefits, which would cause incorrect payments. Because we only collect the information once, we cannot collect it less frequently. There are no technical or legal obstacles to 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 February 15, 2019, at

84 FR 4597, and we received no public comments. The 30-day FRN published on May 22, 2019 at 84 FR 23623. If we receive any comments in response to this Notice, we will forward them to OMB.

9. Payment or Gift 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)
SSA-4111	30,000	1	2	1,000

The total burden for this ICR is 1,000 hours. We based this figure on current management information data. This figure represents burden hours, and we did not calculate a separate cost burden.

13. Annual Cost to the Respondents (Other)

This collection does not impose a known cost burden on the respondents.

14. Annual Cost to Federal Government

The annual cost to the Federal Government is approximately $75,417. This estimate accounts for costs from the following areas: (1) designing, printing, and distributing the form; and (2) SSA employee (e.g., field office, 800 number, DDS staff) information collection and processing time.

15. Program Changes or Adjustments to the Information Collection Request

There are no changes to the public reporting burden.

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 useable forms with expired OMB approval dates, avoiding Government waste.

18. Exceptions 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).

2. Collections of Information Employing Statistical Methods

SSA does not use statistical methods for this information collection.