Appointment of Representative

Forms and Documents

Document Name	Status
Form SSA-1696-U4 Appointment of Representative Form	Modified
Justification for the Non-Substantive Changes - 0596.doc Justification for No Material/Nonsubstantive Change	2011-03-21

IC Document Collections

IC ID	Document Title	Status
9438	Appointment of Representative Form	Modified

ICR Details

OMB Control No: 0960-0527	ICR Reference No: 201103-0960-019
Status: Historical Active	Previous ICR Reference No: 201004-0960-006
Agency/Subagency: SSA	Agency Tracking No:
Title: Appointment of Representative
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/08/2011
	Date Received in OIRA: 03/24/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2014	02/28/2014	02/28/2014
Responses	551,520	0	551,520
Time Burden (Hours)	91,920	0	91,920
Cost Burden (Dollars)	0	0	0

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Abstract: Persons claiming benefits under the Social Security Act must notify SSA in writing when they appoint an individual to represent them in dealings with SSA. SSA collects the information on Form SSA-1696-U4 to verify the appointment of such representatives. The SSA-1696-U4 allows SSA to inform representatives of items affecting the recipient's claim and allows claimants to give permission to their appointed representative to designate a person to copy claims files. Respondents are applicants/recipients of Social Security benefits or Supplemental Security Income payments. This submission is for minor, non-substantive changes to the collection instrument.

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Authorizing Statute(s): US Code: 42 USC 406 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 45190	08/02/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 61550	10/05/2010
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
Appointment of Representative	SSA-1696-U4	Appointment of Representative

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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	551,520	551,520	0	0	0	0
Annual Time Burden (Hours)	91,920	91,920	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: $3,397,363

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: 03/24/2011

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