Acknowledgement of Receipt (Notice of Hearing)

Forms and Documents

Document Name	Status
Form HA-504 Acknowledgement of Receipt (Notice of Hearing)--HA-504 (with teleconferencing) Form	Modified
Form HA-504-OP1 Acknowledgement of Receipt (Notice of Hearing)--HA-504-OP1 (without teleconferencing) Form	Modified
Addendum.doc Supplementary Document	2011-01-20
Supporting Statment 0671.doc Supporting Statement A	2011-01-20

IC Document Collections

IC ID	Document Title	Status
9725	Acknowledgement of Receipt (Notice of Hearing)--HA-504 (with teleconferencing) Form	Modified
183379	Acknowledgement of Receipt (Notice of Hearing)--HA-504-OP1 (without teleconferencing) Form	Modified

ICR Details

OMB Control No: 0960-0671	ICR Reference No: 201010-0960-005
Status: Historical Active	Previous ICR Reference No: 200801-0960-004
Agency/Subagency: SSA	Agency Tracking No:
Title: Acknowledgement of Receipt (Notice of Hearing)
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: 06/08/2011
	Date Received in OIRA: 01/27/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2014	36 Months From Approved	06/30/2011
Responses	700,000	0	600,000
Time Burden (Hours)	350,000	0	300,000
Cost Burden (Dollars)	0	0	0

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Abstract: SSA uses the HA–504 and HA-504-OP1 to acknowledge receipt of the notice of hearing issued by an Administrative Law Judge. The ALJ uses the information to: prepare for the hearing as scheduled; or reschedule the hearing to a different date or location. The only difference between the two forms is the exclusion of the video teleconferencing option on the HA 504 OP1. The respondents are applicants for Social Security benefits who request a hearing to appeal an unfavorable entitlement or eligibility determination.

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Authorizing Statute(s): US Code: 42 USC 405 Name of Law: Social Security Act
   US Code: 42 USC 1383 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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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:
	75 FR 69515	11/12/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 3688	01/20/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Acknowledgement of Receipt (Notice of Hearing)--HA-504 (with teleconferencing)	HA-504	Acknowledgement of Receipt (Notice of Hearing)
Acknowledgement of Receipt (Notice of Hearing)--HA-504-OP1 (without teleconferencing)	HA-504-OP1	Acknowledgement of Receipt (Notice of Hearing)

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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	700,000	600,000	0	0	100,000	0
Annual Time Burden (Hours)	350,000	300,000	0	0	50,000	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: The increase in the annual reporting burden is due to an adjustment in the number of respondents since 2007.

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Annual Cost to Federal Government: $264,786

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

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: 01/27/2011

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