Statement of Employer

Forms and Documents

Document Name	Status
Form SSA-7011-F4 Statement of Employer Form and Instruction	Modified
Addendum 0960-0030.doc Supplementary Document	2015-09-15
Supporting Statement 0960-0030.doc Supporting Statement A	2015-09-08

IC Document Collections

IC ID	Document Title	Status
43689	Statement of Employer Form and Instruction	Modified

ICR Details

OMB Control No: 0960-0030	ICR Reference No: 201505-0960-010
Status: Historical Active	Previous ICR Reference No: 201206-0960-011
Agency/Subagency: SSA	Agency Tracking No:
Title: Statement of Employer
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: 10/22/2015
	Date Received in OIRA: 09/18/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2018	36 Months From Approved	11/30/2015
Responses	500	0	462,000
Time Burden (Hours)	167	0	154,000
Cost Burden (Dollars)	0	0	0

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Abstract: SSA uses Form SSA-7011-F4 to substantiate allegations that earnings posted to the individual’s security record are incorrect, wages paid to the individual do not appear in SSA’s records of earnings, or the individual has no proof of said earnings. SSA uses the information received on this form to process claims for social security benefits and to resolve discrepancies in the individual’s social security earnings record. We only send Form SSA-7011-F4 to employers if we deem it necessary; in many situations, we are able to locate the earnings information within our records, without having to contact the employer. The respondents are certain employers who can verify wage allegations made by the wage earners.

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Authorizing Statute(s): US Code: 42 USC 405 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:
	80 FR 30316	05/27/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 53608	09/04/2015
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 Employer	SSA-7011-F4	Statement of Employer

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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	500	462,000	0	0	-461,500	0
Annual Time Burden (Hours)	167	154,000	0	0	-153,833	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 reduction in burden hours stems from a decrease in the number of respondents. In addition, employers' increase use of electronic reporting during the Annual Wage reporting process increased the speed at which SSA posts earnings, and recognizes and corrects errors in employer reports. Consequently, the incidence of erroneous postings on SSA's earnings records substantially decreased within the past three years. Finally, within the past several years, SSA streamlined development requirements for identifying and resolving potential earnings errors when an individual contacts SSA alleging incorrect earnings on their record. As a result, we decreased the use of Form SSA-7011-F4.

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Annual Cost to Federal Government: $1,000,000

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: 09/18/2015

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