Statement of Living Arrangements, In-Kind Support and Maintenance

Forms and Documents

Document Name	Status
Form SSA-8006-F4 Statement of Living Arrangements, In-Kind Support and Maintenance Form	Modified
Addendum 0174.doc Supplementary Document	2017-11-28
Supporting Statement - 0174.docx Supporting Statement A	2018-02-19

IC Document Collections

IC ID	Document Title	Status
9146	Statement of Living Arrangements, In-Kind Support and Maintenance Form	Modified

ICR Details

OMB Control No: 0960-0174	ICR Reference No: 201711-0960-005
Status: Active	Previous ICR Reference No: 201409-0960-003
Agency/Subagency: SSA	Agency Tracking No:
Title: Statement of Living Arrangements, In-Kind Support and Maintenance
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: 05/08/2018
	Date Received in OIRA: 02/19/2018
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	05/31/2021	36 Months From Approved	05/31/2018
Responses	173,380	0	173,380
Time Burden (Hours)	20,228	0	20,228
Cost Burden (Dollars)	0	0	0

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Abstract: SSA uses Form SSA-8006-F4 in the administration of the Supplemental Security Income (SSI) program. Recipients' need is the basis for determining SSI payments. Need is measured, in part, by the amount of income an individual receives. Income includes in-kind support and maintenance in the form of food and shelter provided by other persons. Form SSA-8006-F4 collects information to ensure that recipients are eligible to receive SSI payments and to determine the correct amount of payments due. The respondents are individuals who apply for SSI payments, or for SSI eligibility redeterminination.

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Authorizing Statute(s): US Code: 42 USC 1382a 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:
	82 FR 55707	11/22/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 4722	02/01/2018
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 Living Arrangements, In-Kind Support and Maintenance	SSA-8006-F4	Statement of Living Arrangements, In-Kind Support and Maintenance

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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	173,380	173,380	0	0	0	0
Annual Time Burden (Hours)	20,228	20,228	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: $476,130

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: 02/19/2018

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