Statement of Income and Resources

Forms and Documents

Document Name	Status
Form SSA-8010 Statement of Income and Resources Form	Modified
Supporting Statement 0960 0124.doc Supporting Statement A	2014-06-18
Addendum to the Supporting Statement 0960-0124.doc Supplementary Document	2014-04-16

IC Document Collections

IC ID	Document Title	Status
9097	Statement of Income and Resources Form	Modified

ICR Details

OMB Control No: 0960-0124	ICR Reference No: 201403-0960-009
Status: Historical Active	Previous ICR Reference No: 201103-0960-012
Agency/Subagency: SSA	Agency Tracking No:
Title: Statement of Income and Resources
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: 07/25/2014
	Date Received in OIRA: 06/25/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2017	36 Months From Approved	07/31/2014
Responses	341,000	0	341,000
Time Burden (Hours)	147,767	0	147,767
Cost Burden (Dollars)	0	0	0

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Abstract: SSA uses Form SSA-8010-BK to collect income and resources information in Supplemental Security Income (SSI) claims and redeterminations. SSA uses the information to make initial or continuing eligibility determinations for SSI claimants/recipients who are subject to deeming. The respondents are persons whose income and/or resources SSA may deem (considered available) in determining the eligibility of SSI claimants or recipients.

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Authorizing Statute(s): US Code: 42 USC 1382 Name of Law: Social Security Act
   US Code: 42 USC 1382a-1382c Name of Law: Social Security Act
   US Code: 42 USC 1382j 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:
	79 FR 17632	03/28/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 34824	06/18/2014
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
Statement of Income and Resources	SSA-8010, SSA-8010-BK	Statement of Income and Resources (MSSICS Screens) ,   Statement of Income and Resources

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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	341,000	341,000	0	0	0	0
Annual Time Burden (Hours)	147,767	147,767	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: $677,431

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: 06/25/2014

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