Agency Information Collection Activities: Proposed Request

The Social Security Administration (SSA) publishes a list of information collection packages requiring clearance by the Office of Management and Budget (OMB) in compliance with Public Law 104-13, the Paperwork Reduction Act of 1995, effective October 1, 1995. This notice includes revisions and one extension of existing OMB-approved information collections.

SSA is soliciting comments on the accuracy of the agency's burden estimate; the need for the information; its practical utility; ways to enhance its quality, utility, and clarity; and ways to minimize burden on respondents, including the use of automated collection techniques or other forms of information technology. Mail, email, or fax your comments and recommendations on the information collection(s) to the OMB Desk Officer and SSA Reports Clearance Officer at the following addresses or fax numbers.

(OMB): Office of Management and Budget, Attn: Desk Officer for SSA.

(SSA): Social Security Administration, OLCA, Attn: Reports Clearance Director, Mail Stop 3253, Altmeyer, 6401 Security Blvd., Baltimore, MD 21235.

Fax: 833-410-1631.

Email address: OR.Reports.Clearance@ssa.gov.

Or you may submit your comments online through www.reginfo.gov/​public/​do/​PRAmain by clicking on Currently under Review—Open for Public Comments and choosing to click on one of SSA's published items. Please reference Docket ID Number [SSA-2026-1090] in your submitted response.

The information collections below are pending at SSA. SSA will submit them to OMB within 60 days from the date of this notice. To be sure we consider your comments, we must receive them no later than November 23, 2026. Individuals can obtain copies of the collection instruments by writing to the above email address.

1. Statement of Self-Employment Income—20 CFR 404.101, 404.110, 404.1096(a)(d)—0960-0046. To ultimately qualify for insured status, and collect Social Security benefits, self-employed individuals must demonstrate they earned the minimum required amount of self-employment income (SEI) in a current year. In cases where an individual is applying for benefits in a specific year, and the resulting quarters of coverage would establish an individual's insured status, SSA initiates the use of Form SSA-766, Statement of Self-Employment Income, to collect the information needed to determine if an individual earned at least the minimum amount of SEI for one or more quarters of coverage in the current year. Based on the information we obtain, we may credit additional quarters of coverage to give the individual insured status where they otherwise may have lacked the necessary earned minimum required amount, thus expediting benefit payments for the year in which they submit the information. Respondents are self-employed individuals potentially eligible for Social Security benefits who are applying for insured status that year.

Type of Request: Revision of an OMB-approved information collection.

2. Farm Arrangement Questionnaire—20 CFR 404.1082(c)—0960-0064. When self-employed farm workers who rent out parts or all of their farm submit earnings data to SSA, they cannot report earnings from the rented farm unless they demonstrate “material participation” in the farm's operation. A “material participation” arrangement means the farm owners must perform a combination of physical duties, management decisions, and capital investment in the farm they are renting out. SSA uses Form SSA-7157, the Farm Arrangement Questionnaire, to document material participation. The respondents are workers who are renting farmland to others, who are nonetheless involved in the operation of the farm, and who want to claim countable income from work they perform relating to the rented farm.

Type of Request: Revision of an OMB-approved information collection.

3. State Mental Institution Policy Review Booklet—20 CFR 404.2035, 404.2065, 416.635, & 416.665—0960-0110. SSA uses Form SSA-9584-BK: (1) to determine if the policies and practices of a state mental institution acting as a representative payee for SSA beneficiaries and payees conform to SSA's regulations in their use of benefits and payments; (2) to confirm institutions are performing other duties and responsibilities required of representative payees; and (3) as the basis for conducting onsite reviews of the institutions and preparing subsequent reports of findings. The respondents are state mental institutions serving as representative payees for Social Security beneficiaries and SSI recipients.

Type of Request: Revision of an OMB approved information collection.

4. Child Relationship Statement—20 CFR 404.355 & 404.731—0960-0116. SSA uses Form SSA-2519, the Child Relationship Statement, to help determine a child's entitlement to Social Security benefits stemming from their relationship with a parent who is an insured worker. Specifically, SSA will use the form to determine if any one of the following qualifying conditions are in place: (1) the child lived with or received contributions from the insured parent at certain times; (2) a court decreed the insured worker to be the child's parent; (3) a court ordered the insured parent to contribute to the child's support; or (4) the insured parent acknowledged in writing that the child is the insured parent's son or daughter. The respondents are people with knowledge of the relationship between insured worker parents and their alleged biological children who can help SSA determine a child's eligibility for Social Security payments based on the parent's insured status.

Type of Request: Revision of an OMB-approved information collection.

5. Claimant's Recent Medical Treatment—20 CFR 404.1512 and 416.912—0960-0292. When Disability Determinations Services (DDS) deny a claim at the reconsideration level for Old Age, Survivors and Disability Insurance (OASDI) or Supplemental Security Income (SSI) payments, the claimant has both a right to request a hearing before a judge, and can submit additional documentation that he or she did not include with the initial application to further support the claim. One such document we ask claimants to complete and return is Form HA-4631. In its current iteration, this Form asks for information not yet on file with us relating to the claimant's medical treatments, including information about their healthcare provider and medical facilities where they received treatment. In this PRA approval cycle, we are proposing to revise Form HA-4631 to incorporate existing Form HA-4632 (OMB No. 0960-0289), Claimant's Medications, which asks the claimant to list and describe all medications they did not previously disclose in their application. Accordingly, the revised HA-4631 will ask claimants or their representatives to submit simultaneously a list of recent medical treatments, current medications, recent physicians and healthcare providers, dates and information regarding recent visits to those providers, and any hospitalizations since the last time the claimant provided SSA (or the DDS) with medical information. In addition, the form will encourage claimants or their representatives to provide any supplemental documentation relating to these topics. We are proposing this new, combined, streamlined approach at the request of advocates for representatives of Social Security claimants. Once we complete this PRA approval cycle and debut the new HA-4631, we will formally discontinue Form HA-4632.

Since claimants may wish to provide new information relating to their claims to establish a basis for an appeals hearing, SSA needs this information to update and complete the claimant's record and to verify the accuracy of the information. Through this process, the judge can ascertain whether the claimant's situation has changed, and can fully investigate the claimant's medical treatment and the effects of the listed medications on the claimant's medical impairments and residual functional capacity. The judge and hearing office staff can also use the responses on the HA-4631 to make arrangements for consultative examination(s) and the attendance of an expert witness(es), if appropriate. The claimant may submit the HA-4631 to SSA via mail or through our Upload Documents portal (OMB No. 0960-0830), or the claimant's representative may submit the form to SSA via mail or Electronic Records Express (OMB No. 0960-0767).

The respondents are claimants, or representatives on behalf of the claimants, who want to provide medical treatment and medicine information to support their request for a hearing to contest a denial of their OASDI or SSI claims.

Type of Request: Revision of an OMB-approved information collection.

6. Disability Report—Adult—20 CFR 404.1512 and 416.912—0960-0579. SSA and State Disability Determination Services (DDS) use Form SSA-3368, Disability Report—Adult, a+nd its electronic versions, to determine if adult disability applicants' impairments are severe and, if so, how the impairments affect the applicants' ability to work. This determination dictates whether the DDSs and SSA will find the applicant to be disabled and entitled to Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) payments. SSA and DDSs request that respondents complete Form SSA-3368 at the same time they complete their application for disability payments (via either the SSA-16 or iClaim, OMB No. 0960-0618, for SSDI, or the SSA-8000 or iSSI, OMB No. 0960-0444, for SSI). Respondents can complete the SSA-3368 as a mail-in paper form, a fillable PDF version through SSA's Upload Documents portal (OMB No. 0960-0830), through a personal interview documented via SSA's Electronic Disability Collect System (EDCS), or through the internet i3368 pathing in SSA's iClaim platform (OMB No. 0960-0618). The respondents are applicants, or third parties on behalf of the applicants, applying for Title II SSDI benefits or Title XVI SSI payments.

Type of Request: Revision of an OMB-approved information collection.

7. The Ticket to Work and Self-Sufficiency Program—20 CFR 411—0960-0644. SSA's Ticket to Work (TTW) Program transitions qualifying Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) recipients toward independence by allowing them to receive Social Security payments while maintaining employment under the auspices of the program. SSA uses service providers, called Employment Networks (ENs), to supervise participant progress through the stages of TTW Program participation, including job searches and interviews; progress reviews; and changes in ticket status. ENs can be private for-profit and nonprofit organizations, as well as state vocational rehabilitation agencies (VRs). SSA and the ENs utilize the TTW program manager to operate the TTW Program and exchange information about participants. For example, the ENs use the program manager to provide updates on tasks such as selecting a payment system or requesting payments for helping the beneficiary achieve certain work goals. Since the ENs are not PRA-exempt, the multiple information collections within the TTW program manager require OMB approval. Most of the categories of information are necessary for SSA to (1) comply with the Ticket to Work legislation, and (2) provide proper oversight of the program. SSA collects this information through several modalities, including forms, electronic exchanges, and written documentation. The respondents are the ENs or state VRs, SSDI beneficiaries, and blind or disabled SSI recipients working under the auspices of the TTW Program.

Type of Request: Revision of an OMB-approved information collection.

Method of completion	Number of respondents	Frequency of response	Number of responses	Average burden per response (minutes)	Estimated total annual burden (hours)	Average theoretical hourly cost amount (dollars) *	Total annual opportunity cost (dollars) **
Ticket Portal
Ticket Assignment—EN & VR Staff (a) 20 CFR 411.140(d)(2))	1,000	91	91,000	2	3,033	* $22.93	** $69,547
Ticket Unassignment—EN & VR Staff (b) 20 CFR 411.145; 411.325)	1,000	2	2,000	15	500	* 22.93	** 11,465
Case Closures Notification—VR Staff (b) 20 CFR 411.535(a)(1)(iii))	150	910	136,500	11	25,025	* 24.91	** 623,373
Electronic File Submission—VR Staff (a) 20 CFR 411.166; 411.170(b))	150	27	4,050	5	338	* 24.91	** 8,420
Tracking Progress—VR Staff (c) 20 CFR 411.200(b))	150	1	150	30	75	* 24.91	** 1,868
Requesting Payments—EN & VR Staff (f) 20 CFR 411.575)	1,000	2	2,000	40	1,333	* 22.93	** 30,566
Contract Changes—EN Staff (d) 20 CFR 411.505)	850	1	850	5	71	* 22.93	** 1,628
Form Alternate Workstation Request
EN Staff	500	1	500	25	208	* 22.93	** 4,769
Annual Performance Outcome Report
EN Management (g) 20 CFR 411.325(f))	345	1	345	120	690	* 42.73	** 29,484
Form EN Ticket Unassignment
EN Staff	25	12	300	15	75	*** 22.93	** 1,720
( printed page 60689)
Form Proof of Relationship
EN Staff (g) 20 CFR 411.325(f))	3,400	2	6,800	20	2,267	* 22.93	** 51,982
Site Visit Questionnaire—Administrative EN
EN Management	2	1	2	180	6	* 42.73	** 256
Site Visit Questionnaire—Traditional EN
EN Management	30	1	30	180	90	** 42.73	** 3,846
Form SSA-1370
Ticketholders (a) 20 CFR 411.140(d)(3); 411.325(a); 411.150(b)(3); 20 CFR 411.465)	40,000	1	40,000	60	40,000	* 14.27	** 570,800
Form SSA-1373
EN Staff (f) 20 CFR 411.575)	1,704	1	1,704	40	1,136	*** 22.93	** 26,048
Form SSA-1374
EN Management (i) 20 CFR 411.320)	345	6	2,070	15	518	* 42.73	*** 22,134
Form SSA-1375
Ticketholders (c) 20 CFR 411.200(b) +	+  1	1	1	1	0	* 1	** 1
Form SSA-1385
Ticketholders (b) 20 CFR 411.145; 411.325)	1,000	1	1,000	10	167	* 14.27	** 2,383
Form SSA-1389
EN Staff (g) 20 CFR 411.325(f))	1,704	1	1,704	40	1,136	* 22.93	** 26,048
Form SSA-1391
EN Staff (f) 20 CFR 411.575)	1,704	1	1,704	40	1,136	* 22.93	** 26,048
Form SSA-1401
EN Staff (f) 20 CFR 411.560 and 411.581)	5	1	5	20	2	* 22.93	** 46
Form TPA Termination Request
EN Management	30	1	30	5	3	* 42.73	** 128
WISE Registration Page
Ticketholders (j) 20 CFR 411.200(b))	10,000	1	10,000	3	500	* 14.27	** 7,135
Grand Totals
Totals	65,095		302,745		78,309		** 1,519,695
+  We are providing a place holder for Form SSA-1375, because SSA is not currently conducting TPRs.
* We based this figure on the average wages of an average Social and Human Service Assistant ($22.93), Rehabilitation Counselor ($24.91), and Social and Community Service Manager ($42.73), as reported by Bureau of Labor Statistics data (Occupational Employment and Wage Statistics) and the average disability payments ($14.27) based on SSA's current FY 2026 data (Effect of COLA on Average Social Security Benefits).
** This figure does not represent actual costs that SSA is imposing on individuals; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the information collection. There is no actual charge to respondents to complete the information collection.

8. Certification of Prisoner Identity Information—20 CFR 422.107—0960-0688. Inmates of Federal, State, or local prisons may need a Social Security card as verification of their Social Security number for school or work programs they attend during incarceration, or as proof of employment eligibility upon release from incarceration. Before SSA can issue a replacement Social Security card, applicants must show SSA proof of their identity. However, people who are in prison for an extended period frequently do not have current identity documents. Therefore, under written agreement with the correctional institution, SSA allows prison officials to verify the identity of certain incarcerated U.S. citizens who need replacement Social Security cards. Prison officials provide SSA information from their official files, sent on correctional facility letterhead. SSA uses this information to establish the applicant's identity in the replacement Social Security card process. The respondents are prison officials who certify the identity of prisoners applying for replacement Social Security cards.

Type of Request: Revision of an OMB-approved information collection. ( printed page 60690)

9. Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery—0960-0788. As part of our continuing effort to reduce paperwork and respondent burden, SSA invites the general public to comment on the “Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery ” for approval under the Paperwork Reduction Act (PRA) (44 U.S.C. 3501 et. seq.). We developed and use this collection as part of a Federal Government-wide effort to streamline the process for seeking feedback from the public on service delivery.

Under the auspices of Executive Order 12862, Setting Customer Service Standards, SSA conducts multiple satisfaction surveys each year. This information collection activity provides a means to garner qualitative customer and stakeholder feedback in an efficient, timely manner, in accordance with SSA's commitment to improving service delivery. By qualitative feedback we mean information that provides useful insights on perceptions and opinions, but are not statistical surveys that yield quantitative results that can be generalized to the population of study. This feedback provides insights into customer or stakeholder perceptions, experiences, and expectations; provides an early warning of issues with service; or focuses attention on areas where communication, training, or changes in operations might improve delivery of products or services. These collection activities allow for ongoing, collaborative, and actionable communications between SSA and our customers and stakeholders.

The solicitation of feedback targets areas such as: timeliness; appropriateness; accuracy of information; courtesy; efficiency of service delivery; and resolution of issues with service delivery. We assess responses to plan and inform efforts to improve or maintain the quality of service offered to the public. If we did not collect this information, we would not have access to vital feedback from customers and stakeholders on SSA's services.

We only submit a collection for approval under this generic clearance if it meets the following conditions: (1) the collections are voluntary; (2) the collections are low-burden for respondents (based on considerations of total burden hours, total number of respondents, or burden-hours per respondent) and are low-cost for both the respondents and the Federal Government; (3) the collections are non-controversial and do not raise issues of concern to other Federal agencies; (4) any collection targeted to the solicitation of opinions from respondents who have experience with the program or may have experience with the program in the near future; (5) we collect personally identifiable information (PII) only to the extent necessary and we do not retain it; (6) we will use information gathered only internally for general service improvement and program management purposes and we will not release it outside of the agency; (7) we will not use information we gather for the purpose of substantially informing influential policy decisions; and (8) information we gather will yield qualitative information; the collections will not be designed or expected to yield statistically reliable results or used as though the results are generalizable to the population of study.

Feedback collected under this generic clearance provides useful information, but it does not yield data that can be generalized to the overall population. This type of generic clearance for qualitative information will not be used for quantitative information collections that are designed to yield reliably actionable results, such as monitoring trends over time or documenting program performance. Such data uses require more rigorous designs that address the target population to which generalizations will be made, the sampling frame, the sample design (including stratification and clustering), the precision requirements or power calculations that justify the proposed sample size, the expected response rate, methods for assessing potential non-response bias, the protocols for data collection, and any testing procedures that were or will be undertaken prior to fielding the study. Depending on the degree of influence the results are likely to have, such collections may still be eligible for submission for other generic mechanisms that are designed to yield quantitative results.

As a general matter, information collections will not result in any new system of records containing privacy information and will not ask questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private.

The respondents are recipients of SSA services, professionals, and individuals who work on behalf of SSA beneficiaries (including most members of the public such as individuals and households, businesses and organizations, and State, Local, or Tribal governments).

Type of Request: Extension of an OMB-approved information collection.

10. Data Exchange Request Form—20 CFR 401.100—0960-0802. SSA maintains approximately 2,000 data exchange agreements with, and regularly receives new data exchanges requests from, Federal, State, local, and tribal agencies; foreign governments; and research entities and private organizations to share data electronically. SSA engages in various forms of data exchanges from Social Security number verifications to computer matches for benefit eligibility, depending on the requestor's business needs. Section 1106(b) of the Social Security Act requires SSA to consider the requestor's legal authority to receive the data, our disclosure policies, systems' feasibility, systems' security, and costs before entering into a data exchange agreement. We use Form SSA-157, Data Exchange Request Form and its electronic version (DXRF), for this purpose. Requesting agencies, governments, or private organizations complete and email in the SSA-157, or use the electronic DXRF platform, when voluntarily initiating a request for data exchange from SSA. Respondents are State, local, or tribal agencies; foreign governments; research entities; or private organizations that are voluntarily initiating a request to receive data electronically from SSA via data exchange.

Type of Request: Revision of an OMB-approved information collection.

11. Statement Regarding the Inferred Death of an Individual by Reason of Continued and Unexplained Absence—20 CFR 404.720 & 404.721—0960-0844. Section 202(d)-(i) of the Social Security Act (Act) provides for the payment of various monthly survivor benefits, and a lump sum death payment, to certain survivors upon the death of an individual who dies while currently insured. In cases where insured wage earners have been absent from their homes for at least seven years, and there is no evidence these individuals are alive, SSA may presume they are deceased and will pay their survivors the appropriate benefits. SSA uses the information Form SSA-723 provides to determine if we may presume a missing wage earner is deceased, and, if so, to establish a date of presumed death. The respondents are relatives, friends, neighbors, or acquaintances of the presumed deceased wage earner, or the person who is filing for survivor's benefits.

Type of Request: Revision of an OMB-approved information collection.