OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Request for Hearing By Administrative Law Judge

ICR 201102-0960-007 · OMB 0960-0269 · Historical Active

Forms and Documents
Document
Name
Status
Form
 Modified
Form and Instruction
 Modified
Supporting Statement A
2011-05-31
Supplementary Document
2011-05-31
IC Document Collections
IC ID
Document
Title
Status
9174 Modified
180726 Modified
ICR Details
0960-0269 201102-0960-007
Historical Active 201002-0960-021
SSA
Request for Hearing By Administrative Law Judge
Revision of a currently approved collection   No
Regular
Approved without change 09/30/2011
Retrieve Notice of Action (NOA) 06/02/2011
OMB is approving this collection for one year with the following terms of clearance. Upon next submission, SSA should provide a written explanation of the reasons for the wide discrepancy between the average burden associated with the electronic form and the paper version. The explanation should include steps that SSA is taking to reduce this discrepancy. SSA should also provide OMB with up-to-date data on the percentage of Medicare Part B affected beneficiaries who request an appeals hearing.
  Inventory as of this Action Requested Previously Approved
09/30/2014 36 Months From Approved 09/30/2011
669,469 0 669,469
206,978 0 161,788
0 0 0
SSA uses the information collected on Form HA-501-U5 to document and initiate the Administrative Law Judge (ALJ) hearing process for determining eligibility or entitlement to Social Security benefits (Title II), Supplemental Security Income payments (Title XVI), Special Veterans Benefits (Title VIII), Medicare (Title XVIII), and of initial determinations regarding Medicare Part B income-related premium subsidy reductions. The respondents are individuals filing for an ALJ hearing.
PL: Pub.L. 103 - 296 105(a)(2)(B) Name of Law: Social Security Independence and Program Improvements Act
   US Code: 42 USC 405 Name of Law: Social Security Act
   US Code: 42 USC 1320c-4 Name of Law: Social Security Act
   US Code: 42 USC 1383 Name of Law: Social Security Act
   US Code: 42 USC 1395ff Name of Law: Social Security Act
   US Code: 42 USC 1395r Name of Law: Social Security Act
   PL: Pub.L. 108 - 173 1350 & 931 Name of Law: Medicare Modernization Act of 2003
   PL: Pub.L. 106 - 169 251 & 809 Name of Law: Foster Care Independence Act of 1999
  
None
Not associated with rulemaking
  76 FR 11835 03/03/2011
76 FR 30749 05/26/2011
No
  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 669,469 669,469 0 0 0 0
Annual Time Burden (Hours) 206,978 161,788 0 0 45,190 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
There has been an increase in burden hours, due to more respondents completing the form online.
$55,000
No
No
No
No
No
Uncollected
Faye Lipsky 410 965-8783 faye.lipsky@ssa.gov
  No
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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
06/02/2011