Application for Lump-Sum Death Payment

Forms and Documents

Document Name	Status
Form SSA-8-F4 Application for Lump-Sum Death Payment - Paper Form	Modified
Addendum - 0013.docx Supplementary Document	2016-07-04
Supporting Statement - 0013.docx Supporting Statement A	2016-07-04

IC Document Collections

IC ID	Document Title	Status
8890	Application for Lump-Sum Death Payment - Paper Form	Modified
44962	Application for Lump-Sum Death Payment--Modernized Claims System (MCS) Other-Internal Use Screens	Modified

ICR Details

OMB Control No: 0960-0013	ICR Reference No: 201603-0960-004
Status: Historical Active	Previous ICR Reference No: 201303-0960-013
Agency/Subagency: SSA	Agency Tracking No:
Title: Application for Lump-Sum Death Payment
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: 08/17/2016
	Date Received in OIRA: 07/04/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2019	36 Months From Approved	08/31/2016
Responses	670,248	0	587,000
Time Burden (Hours)	100,674	0	88,540
Cost Burden (Dollars)	0	0	0

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Abstract: SSA uses Form SSA-8-F4 to collect information needed to authorize payment of the lump-sum death payment (LSDP) to a widow, widower, or children as defined in Section 202(i) of the Act. Respondents complete the application for this one-time payment via paper form, telephone, or during an in-person interview with SSA employees. Respondents are applicants for the LSDP.

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Authorizing Statute(s): US Code: 42 USC 402 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:
	81 FR 19283	04/04/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 39990	06/20/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Application for Lump-Sum Death Payment--Modernized Claims System (MCS)
Application for Lump-Sum Death Payment - Paper	SSA-8-F4	Application For Lump-Sum Death Payment

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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	670,248	587,000	0	83,248	0	0
Annual Time Burden (Hours)	100,674	88,540	0	12,134	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Using Information Technology

Short Statement: The change in the public reporting burden stems from combining the MCS and signature proxy collections. Since each method had a different response time by a minute, which changed the reported burden hours. We no longer require separate burden for our MCS collections, because we complete all MCS claims through signature proxy attestation, unless the applicant prefers to provide a wet signature. Therefore, we are combining the MCS and signature proxy collections.

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Annual Cost to Federal Government: $89,841

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: 07/04/2016

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