SSA uses the information we gather on the SSA-8510 and accompanying Modernized Supplemental Security Income Claims System (MSSICS) screens to determine if individuals are eligible for specific Social Security or Medicare Part D benefits, or for Supplemental Security Income (SSI) payments. SSA uses the SSA-8510 to contact a public or private custodian of records and request evidence information to support a benefit application or payment continuation. We ask for evidence information such as the following: Age requirements (e.g. birth certificate, court documents); Insured status (e.g. earnings, employer verification); Marriage or divorce information; Pension Offsets; Wages verification; Annuities; Property information; Benefit verification from a State agency or third party; Immigration status (rare instances); Income verification from public agencies or private individuals; Unemployment benefits; Insurance Policies. If the custodian requires a signed authorization from the individual(s) whose information SSA requests, SSA provides the custodian with a copy of the SSA-8510. Once the respondent completes the SSA 8510, either using the paper form, or through a personal interview during which an SSA employee completes the MSSICS version, SSA uses the form as the authorization to obtain personal information regarding the respondent from third parties until the authorizing person (respondent) revokes the permission of its usage. The collection is voluntary; however, failure to verify the individuals' eligibility can prevent SSA from making an accurate and timely decision for their benefits. The respondents are individuals who file for, or currently receive, Social Security benefits, SSI payments, or Medicare Part D subsidies.
US Code:
42 USC 1383
Name of Law: Social Security Act
US Code:
42 USC 405
Name of Law: Social Security Act
This form is currently in use under OMB Number 0960-0707 under which we only reported the Medicare Part D usage; therefore, our estimate for general purposes is in use without an OMB number. Since we are currently reporting the expanded usage for general purposes, which increases the public burden, we are also requesting a new OMB number as our information collection for 0960-0707 covers only Medicare, and we currently use this form for other SSA programs as well (as indicated in #2 of the Supporting Statement). In addition, we are also including a new electronic version of the SSA 8510 in MSSICS, which also changes the total burden.
$1,281
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.
Form SSA-8510 SSA-8510 – Title II and Title XVI general evidence (paper version)
Addendum - SSA-8510.docx
SSA-8510 – Title II and Title XVI general evidence (MSSICS version)