Supporting Statement - 0024 (Final)

Supporting Statement for Form SSA-787

Medical Source Opinion of Patient’s Capability to Manage Benefits

20 CFR 404.2015 and 416.615

OMB No. 0960-0024

A. Justification

1. Introduction/Authoring Laws and Regulations

The Social Security Administration (SSA) appoints representative payees on behalf of beneficiaries if we determine the beneficiaries are incapable of managing or directing the management of those benefits. Sections 205, 807, and 1631(a) of the Social Security Act (Act) specifically state SSA has the authority to appoint a representative payee on behalf of a beneficiary. SSA only makes a finding of incapability and appoints a representative payee when it is clearly in the beneficiary’s best interest, based on convincing evidence using sound and reasoned judgment. 20 CFR 404.2015 and 416.615 of the Code of Federal Regulations require legal, lay, and medical evidence to determine if a beneficiary is capable of managing or directing the management of benefits payments.

2. Description of Collection

SSA appoints a representative payee in cases where we determine beneficiaries are not capable of managing their own benefits. In these instances, we require medical evidence to determine the beneficiaries’ capability of managing or directing their benefit payments. SSA collects medical evidence on

Form SSA-787 to: (1) determine beneficiaries’ capability or inability to handle their own benefits; and (2) assist in determining the beneficiaries’ need for a representative payee. The respondents are the beneficiary’s physicians, or medical officers of the institution in which the beneficiary resides.

2. Use of Information Technology to Collect the Information

SSA is unable to create an electronic version of this information collection at this time, as we send this agency-initiated application to respondents with pre-filled information.  We also include a bar code which allows us to scan the completed form into the electronic folder once we receive it from the respondent.  Currently, we do not have any means to pre-fill information and send the individualized forms to the respondents electronically, as that would require us to create new backend systems, and we do not currently have those scheduled for construction through our IT Mod schedule. Given that IT Mod programming is an ongoing, dynamic project, we cannot provide specific timelines for when we will be able to make any particular ICR available via Internet web-based application.  We will ultimately convert most existing ICRs to full electronic versions depending on how they fall within our overall IT Mod schema, but this may be unconnected to the PRA approval lifecycle.  In addition, we cannot send these pre-filled forms via email, as the pre-filled information contains personal identifying information (PII) of the respondents, and email is a non-secured means of transferring PII.  Finally, we evaluated this collection for conversion to a submittable PDF, as we have successfully converted another pre-filled form to a submittable PDF.  However, given the high volume of conversions we are coordinating and the more urgent nature of some of the other conversions, we ultimately decided not to prioritize this ICR for conversion to fully submittable PDF at this time.  When we are able to schedule this form for conversion to a submittable PDF, we will submit a Change Request to OMB to request prior approval.

2. Why We Cannot Use Duplicate Information

The nature of the information we collect and the manner in which we collect it precludes 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-787, SSA might not collect the necessary medical evidence for use in determining if beneficiaries are capable of managing their funds with or without a representative payee. Because we collect this information on an as needed basis, 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 August 23, 2021, at

86 FR 47190, and we received no public comments. The 30-day FRN published on November 18, 2021 at 86 FR 64585. If we receive any comments in response to this Notice, we will forward them to OMB. We did not consult with the public in the revision/maintenance of this form.

8. Payment or Gifts to Respondents

SSA does not provide payments or gifts to the respondents.

8. 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.

8. Justification for Sensitive Questions

The information collection contains some questions that may lead to the disclosure of sensitive information since we may include the beneficiary's medical history in the collection. However, this information is necessary to determine if a beneficiary can receive benefits directly.

8. Estimates of Public Reporting Burden

Modality of Completion	Number of Respondents	Frequency of Response	Average Burden per Response (minutes)	Estimated Total Annual Burden (hours)	Average Theoretical Hourly Cost Amount (dollars)*	Total Annual Opportunity Cost (dollars)**
SSA-787	767,737	1	20	255,912	$105.22*	$26,927,061**

* We based this figure on the national average medical professionals’ salaries as reported by the US Bureau of Labor Statistics data (https://www.bls.gov/oes/current/oes291228.htm)

** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the form. There is no actual charge to respondents to complete the form.

We base our burden estimates on current management information data, which includes data from actual interviews, as well as from years of conducting this information collection.  Per our management information data, we believe that the average time in minutes listed in the chart above accurately shows the average burden per response for reading the instructions, gathering the facts, and answering the questions. Based on our current management information data, the current burden information we provided is accurate. The total burden for this ICR is 255,912 burden hours (reflecting SSA management information data), which results in an associated theoretical (not actual) opportunity cost financial burden of $26,927,061. SSA does not charge respondents to complete our applications.

13. Annual Cost to the Respondents (Other)

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

14. Annual Cost to the Federal Government

The annual cost to the Federal Government is approximately $3,686,692. This estimate accounts for costs from the following areas:

Description of Cost Factor	Methodology for Estimating Cost	Cost in Dollars*
Designing and Printing the Form	Design Cost + Printing Cost	$8,000
Distributing, Shipping, and Material Costs for the Form	Distribution + Shipping + Material Cost	$850,000
SSA Employee (e.g., field office) Information Collection and Processing Time	GS-9 employee salary x # of responses x processing time	$2,825,272
Full-Time Equivalent Costs	Out of pocket costs + Other expenses for providing this service	$0*
Systems Development, Updating, and Maintenance	GS-9 employee x man hours for development, updating, maintenance	$3,420
Quantifiable IT Costs	Any additional IT costs	$0*
Total		$3,686,692

* We have inserted a $0 amount for cost factors that do not apply to this collection.

SSA is unable to break down the costs to the Federal government further than we already have.  First, since we work with almost every US citizen, we often do bulk mailings, and cannot track the cost for a single mailing.  In addition, it is difficult for us to break down the cost for processing a single form, as field office and State Disability Determination Services staff often help respondents fill out several forms at once, and the time it takes to do so can vary greatly per respondent.  As well, because so many employees have a hand in each aspect of our forms, we use an estimated average hourly wage, based on the wage of our average field office employee (GS-9) for these calculations.  However, we have calculated these costs as accurately as possible based on the information we collect for creating, updating, and maintaining these information collections.

15. Program Changes or Adjustments to the Information Collection Request

When we last cleared this IC in 2018, the burden was 43,852 hours. However, we are currently reporting a burden of 255,912 hours. This change stems an increase in the number respondents using form SSA-787, and an increase of responses from 131,556 to 767,737. There is no change to the burden time per response. Although the number of responses changed, SSA did not take any actions to cause this change. These figures represent current Management Information data.

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).

B. Collections of Information Employing Statistical Methods

SSA does not use statistical methods for this information collection.

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