Agency Information Collection Activities: Comment 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 of 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-2026-1189] in your submitted response.

SSA submitted the information collections below to OMB for clearance. To be sure OMB and SSA consider your comments regarding these information collections, we must receive them no later than November 30, 2026. Individuals can obtain copies of the OMB clearance packages by writing to the OR.Reports.Clearance@ssa.gov.

1. Statement of Income and Resources—20 CFR 416.207, 416.302-416.310, 416.704, 416.708, and 416.1160—0960-0124. SSA collects information about income and resources for Supplemental Security Income (SSI) claims and redeterminations on the SSA-8010-BK from third party individuals ( e.g., parents, spouses, guardians, or other individuals typically in the role of representative payee) who support the SSI applicant or recipient. SSA uses the information from the SSA-8010-BK to make initial or continuing eligibility determinations for SSI claimants or recipients who are subject to deeming. The respondents are third party individuals who support SSI claimants or recipients, and whose income and resources SSA may deem (consider to be available as their own) to SSI applicants or recipients.

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

2. Waiver of Your Right to Personal Appearance before a Judge—20 CFR 404.930, 404.948(b)(1)(i), 404.957, 416.1430, 416.1448(b)(1)(i), and 416.1457—0960-0284. Applicants for Social Security, Old Age, Survivors, and Disability Insurance (OASDI) benefits and SSI payments have the statutory right to personally appear (either on their own or through a representative) and present evidence about their claims at a hearing before a judge. Per SSA regulations, if a claimant is dissatisfied with a determination or decision listed in 20 CFR 404.930 or 416.1430, the claimant may request a hearing before a judge and has a right to appear at a hearing before a judge. At a hearing, claimants have the right to present evidence; have witnesses testify on their behalf; and present their cases to the judge. A hearing may provide the judge with additional information to make a more informed decision on the case. However, in some cases, claimants may choose to waive their right to appear before a judge for various reasons, including if they feel the evidence of record stands on its own, or if they are unable to attend a hearing due to extenuating circumstances. When a claimant chooses to waive the right to appear at a hearing and allows the judge to decide the case based on the written evidence of record alone, we ask the claimant to submit this request to us in writing so we can document it in their record. While SSA will accept a written request, we also allow claimants to use Form HA-4608 to serve as a written waiver for the claimant's right to a personal appearance before a judge. The claimant may complete the paper version of the HA-4608 and mail it back to SSA using the pre-paid envelope SSA sends with it, or the claimant may choose to complete the submittable PDF version of the HA-4608 through SSA's Upload Documents Portal (OMB No. 0960-0830) on SSA's website. The judge uses the information we collect on Form HA-4608 to continue processing the case and makes the completed form a part of the documentary evidence of record by placing it in the official record of the proceedings as an exhibit. Respondents are applicants or claimants for OASDI and SSI, or their representatives, who request to waive their right to appear before a judge.

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

3. Request for Change in Time/Place of Disability Hearing—20 CFR 404.91(c)(2) and 416.1414(c)(2)—0960-0348. At the request of the claimants or their representatives, SSA schedules evidentiary hearings at the reconsideration level for claimants of Title II benefits or Title XVI payments when we deny their claims for disability. When claimants or their representatives find they are unable to attend the scheduled hearing, they complete Form SSA-769 to request a change in time or place of the hearing. SSA uses the information from the form as a basis for granting or denying requests for changes and for rescheduling disability hearings. Respondents are claimants or their representatives who wish to request a change in the time or place of their reconsideration hearing.

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

4. Marital Relationship Questionnaire—20 CFR 416.1826—0960-0460. SSA uses Form SSA-4178, Marital Relationship Questionnaire, to determine if unrelated individuals of the opposite sex who live together are presenting themselves as husband and wife. SSA needs this information to determine whether we are making correct payments to couples and individuals applying for, or currently receiving, Supplemental Security Income (SSI) payments. The respondents are applicants for, and recipients of, SSI payments.

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

5. Employer Verification of Earnings After Death—20 CFR 404.821 and 404.822—0960-0472. When SSA records show a wage earner is deceased, and we receive wage reports from an employer for the wage earner for a year subsequent to the year of death, SSA mails the employer Form SSA-L4112 (Employer Verification of Earnings After Death). SSA uses the information provided on Form SSA-L4112 to verify that the wage information previously received from the employer is correct for the employee and the year in question (the year following the employee's death). This process helps ensure the accuracy and integrity of earnings records. The respondents are employers who report wages for employees who have died.

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

6. Pain Report Child—20 CFR 404.1512 and 416.912—0960-0540. Before SSA can make a disability determination for a child, we require evidence from parents, guardians, or individuals who know the child well and observe their daily life and symptoms to prove their disability. Form SSA-3371-BK provides disability interviewers, and SSI applicants or claimants in self-help situations, with a convenient way to record information claimants' pain or other symptoms. The State disability determination services adjudicators and judges use the information from Form SSA-3371-BK to assess the effects of symptoms on function for purposes of determining disability under the Act. The respondents are parents, guardians, or individuals who know a child SSI applicant or recipient well.

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

7. Wage Reports and Pension Information—20 CFR 422.122(b)—0960-0547. Pension plan administrators annually file plan information with the Internal Revenue Service, which then forwards the information to SSA. SSA maintains and organizes this information by plan number, plan participant's name, and Social Security ( printed page 68216) number. Per section 1131(a) of the Act, pension plan participants are entitled to request this information from SSA. The Wage Reports and Pension Information regulation, 20 CFR 422.122(b) of the Code of Federal Regulations, stipulates that before SSA disseminates this information, the requestor must first submit a written request with identifying information to SSA. The respondents are Social Security number holders who are requesting information about that pension plan from SSA.

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

8. Work Incentives Planning and Assistance Program (WIPA) Star System, SSA-4565, and SSA-4566—0960-0629. As part of SSA's strategy to assist Social Security Disability Insurance (SSDI) beneficiaries and Supplemental Security Income (SSI) recipients who wish to return to work and achieve self-sufficiency, SSA established the Work Incentives Planning and Assistance (WIPA) program. This community-based, work incentive, planning and assistance project collects identifying claimant information via project sites and community work incentives coordinators (CWIC) through the WIPA Star System. SSA uses this information to ensure proper management of the project, with particular emphasis on administration, budgeting, and training. SSA uses Form SSA-4565 (WIPA Intake Information) to collect data from SSDI beneficiaries and SSI recipients on background employment, training, benefits, and work incentives. CWICs use Form SSA-4566 (WIPA Notes) to create a case note to record actions taken for a beneficiary. In addition, CWIC mangers use Form SSA-451 (WIPA Manager Report) to complete and submit a quarterly report to SSA. The CWICs primarily use the WIPA Star System that allows the CWIC to: (1) provide SSA with information provided on Form SSA-4565, and additional information on beneficiaries served under the WIPA program; (2) manage their case notes for beneficiaries; (3) collect additional information not collected on Forms SSA-4565 and SSA-4566 which allows SSA to monitor WIPA grantee's performance and progress; and (4) allow the CWIC mangers to complete and submit the SSA-451 quarterly report to SSA. The respondents are SSDI beneficiaries, SSI recipients, community project sites, and community work incentives coordinators.

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

9. Internet Direct Deposit Application—31 CFR 210—0960-0634. SSA requires all applicants and recipients of Social Security OASDI benefits, or Supplemental Security Income (SSI) payments to receive these benefits and payments via direct deposit, at a financial institution. SSA receives Direct Deposit/Electronic Funds Transfer (DD/EFT) enrollment information from OASDI beneficiaries and SSI recipients to facilitate DD/EFT of their funds, with their chosen financial institution. We also use this information when an enrolled individual wishes to change their DD/EFT information. For the convenience of the respondents, we collect this information through several modalities, including an internet application, in-office or telephone interviews, and our automated telephone system. Respondents are OASDI beneficiaries and SSI recipients requesting that we enroll them in the Direct Deposit program or change their direct deposit banking information.

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

10. Notice to Electronic Information Exchange Partners to Provide Contractor List—0960-0820. The Federal standards Privacy Act of 1974; E-Government act of 2002; and the National Institute of Standards and Technology Special Publications 800-53-4, require SSA to maintain oversight of the information it provides to Electronic Information Exchange Partners (EIEPs). EIEPs obtain SSA data for the administration of federally funded and state-administered programs. SSA has a responsibility to monitor and protect the personally identifiable information SSA shares with other Federal and State agencies. EIEPs agree to comply with Electronic Information Exchange security requirements and procedures for State and local Agencies exchanging electronic information with SSA. SSA's Technical Systems Security Requirements document provides that all agencies using SSA data must ensure SSA information is not processed; maintained; transmitted; or stored in; or by means of data communications channel; electronic devices; computers; or computer networks located in geographic or virtual areas not subject to U.S. law. SSA conducts tri-annual compliance reviews of all State and local agencies, and Tribes with whom we have an IEA, to verify appropriate security safeguards remain in place to protect the confidentiality of information SSA supplies. SSA requires any organization with an electronic data exchange agreement to provide SSA with a current list of contractors, or agents who have access to SSA data upon request. SSA uses Form SSA-731, Notice to Electronic Information Exchange Partners to Provide Contractor List to collect the list of current contractors. The respondents are Federal agencies and State, local, or tribal agencies who exchange electronic information with SSA.

Type of Request: Revision of an OMB approved information collection. ( printed page 68218)

11. State of Georgia's Criminal Justice Coordinating Council's (CJCC) Evaluation of the Implementation of the Supplemental Security Income (SSI)/Social Security Disability Insurance (SSDI) Outreach, Access, and Recovery (SOAR) Model in County Jails—0960-0833. SSA is in a cooperative agreement with the State of Georgia's Criminal Justice Coordinating Council (CJCC) to conduct an intervention and evaluation of the Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) Outreach, Access, and Recovery (SOAR) model in county jails with inmates with serious and persistent mental illness (SPMI) across the state. In addition to SSA, CJCC partnered with: (1) Applied Research Services (ARS), (2) the Georgia Department of Behavioral Health and Developmental Disabilities (DBHDD), and (3) four county jails to implement the program. For this intervention, investigators hypothesized that untreated mental illness and repeated psychiatric crises may be a factor in jail recidivism. Therefore, the ability for inmates with SPMI to receive SSI/SSDI and attendant insurance benefits may help them obtain treatment and thus help to mitigate their criminal tendencies. This intervention connects respondents in four county jails identified as having SPMI to Medicaid Eligibility Specialists (MES) hired and trained by the Georgia DBHDD, who help them apply for SSI and SSDI. Respondents in two of the four counties (Fulton County Jail and Cobb County Jail) also have the option of working with a Forensic Peer Mentor (FPM), a formerly incarcerated individual who is familiar with resources that may help participants increase their quality-of-life post incarceration and avoid recidivism. SSA works with the two DBHDD MESs who are serving the participants over the total life of the project. To maximize the likelihood of the SSI/SSDI application approval, the MES employs the SOAR method, which uses in-depth medical and personal summaries of disability to facilitate the SSI/SSDI application process. Researchers collect data from participant surveys to evaluate and study the impact of the intervention. Through the data collected through these surveys, along with administrative data from SSA, the State of Georgia, participating counties, and DBHDD hope to address the following research questions:

• Does connection to a SOAR-trained specialist increase the likelihood that a person with SPMI in jail will be approved for SSI/SSDI benefits?
• If a person with SPMI receives SSI/SSDI benefits, are they able to connect to treatment resources that they may not have been able to obtain before?
• If a person with SPMI connects to treatment resources and successfully engages with them, are they able to achieve mental health recovery and stay out of jail?

To date, we began the initial enrollment and informed consent phase of this intervention, and we are currently completing this stage. We also began the follow-up survey stage for the first set of enrollees in the intervention, and we will continue to administer the follow-up survey as needed through 2027 until we complete this phase with all the respondents.

The respondents are individuals with serious and persistent mental illness incarcerated in county jails in the state of Georgia.

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

The following chart shows the current burden information for the remaining information collections associated with this intervention: