SSA Guidance for Use of the Tax Information Authorization Form

Forms and Documents

Document Name	Status
0960-0738 regular clearance supporting statement.doc Supporting Statement A	0000-00-00
IRS Form 8821.pdf Supplementary Document	2007-01-03
Disclosure Authorization Plan.doc Supplementary Document	2007-01-03
IRS Agreement Letter.pdf Supplementary Document	2007-01-03
IRS Form 8821 Emergency Clearance Request Letter.doc Supplementary Document	2007-01-03

IC Document Collections

IC ID	Document Title	Status
46610	SSA Guidance for Use of the Tax Information Authorization Form Instruction	Modified

ICR Details

OMB Control No: 0960-0738	ICR Reference No: 200703-0960-008
Status: Historical Active	Previous ICR Reference No: 200701-0960-001
Agency/Subagency: SSA	Agency Tracking No:
Title: SSA Guidance for Use of the Tax Information Authorization Form
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/22/2007
	Date Received in OIRA: 03/30/2007
Terms of Clearance: OMB approves this collection consistent with the e-mail with SSA on 5/22/07, where SSA will develop and submit their own authorization form for approval upon expiration of this collection.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2008	36 Months From Approved	07/31/2007
Responses	6,000	0	6,000
Time Burden (Hours)	1,500	0	1,500
Cost Burden (Dollars)	0	0	0

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Abstract: The Internal Revenue Service (IRS) Form 8821 is used by taxpayers to authorize the release of tax information to a third party. The IRS agrees that a properly completed IRS Form 8821 is an appropriate means of designating the Department of Health and Human Services (HHS) to receive the tax information of a Medicare Part B beneficiary who has appealed a determination of Income-Related Monthly Adjustment Amount (IRMAA). Specifically, Medicare Part B beneficiaries who wish to appeal SSA's reconsideration of their IRMAA amounts will be sent a copy of the HA-501 (Request for Hearing by an Administrative Law Judge) and with it the IRS Form 8821, which will enable beneficiaries to authorize disclosure of their relevant beneficiary tax data to HHS for use in conducting the appeals hearing. The respondents are Medicare Part B beneficiaries who want to request an appeal of their IRMAA amount.

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Authorizing Statute(s): PL: Pub.L. 108 - 173 811 Name of Law: Medicare Modernization Act of 2003
   US Code: 26 USC 6103(a) Name of Law: null
  

Citations for New Statutory Requirements: PL: Pub.L. 108 - 173 811 Name of Law: Medicare Modernization Act of 2003

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 4764	02/01/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 15175	03/30/2007
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
SSA Guidance for Use of the Tax Information Authorization Form

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ICR Summary of Burden

	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	6,000	6,000	0	0	0	0
Annual Time Burden (Hours)	1,500	1,500	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 03/30/2007

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