Agency/Employer Government Pension Offset Questionnaire

Forms and Documents

Document Name	Status
Form SSA-L4163 Agency/Employer Government Pension Offset Questionnaire Form	Modified
Justification for Non-Substantive Changes - 0470.docx Justification for No Material/Nonsubstantive Change	2017-08-03

IC Document Collections

IC ID	Document Title	Status
9355	Agency/Employer Government Pension Offset Questionnaire Form	Modified

ICR Details

OMB Control No: 0960-0470	ICR Reference No: 201708-0960-001
Status: Historical Active	Previous ICR Reference No: 201602-0960-012
Agency/Subagency: SSA	Agency Tracking No:
Title: Agency/Employer Government Pension Offset Questionnaire
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: 08/28/2017
	Date Received in OIRA: 08/04/2017
Terms of Clearance: In accordance with 5 CFR 1320, the information collection is approved for three years.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2019	08/31/2019	08/31/2019
Responses	1,000	0	1,000
Time Burden (Hours)	50	0	50
Cost Burden (Dollars)	0	0	0

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Abstract: When individuals are concurrently receiving Social Security benefits and a government pension, SSA may reduce the individual's Social Security benefits by the government pension amount; this is called the Government Pension Offset (GPO). SSA uses the SSA-L4163 to collect accurate pension information for purposes of applying the pension offset provision. SSA uses the form only when (1) the claimant does not have the information and (2) the pension-paying agency has not cooperated with the claimant. Respondents are State government or private pension paying agencies that have information needed by SSA to determine if the GPO applies and the amount of offset. We are making Non-Substantive changes to the form to remove a duplicate sentence, correct grammar, and update the PRA Statement.

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Authorizing Statute(s): US Code: 42 USC 402 Name of Law: Old-age and Survivors Insurance Benefit Payments
  

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 11636	03/04/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 31999	05/20/2016
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
Agency/Employer Government Pension Offset Questionnaire	SSA-L4163	Agency/Employer Government Pension Offset Questionnaire

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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	1,000	1,000	0	0	0	0
Annual Time Burden (Hours)	50	50	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: $231,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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: 08/04/2017

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