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Federal Register / Vol. 86, No. 168 / Thursday, September 2, 2021 / Notices
Number of respondents
Modality of completion
SSA1699

I

Average burden per response minutes
Frequency of response
I

10,382

I

1

Average theoretical hourly cost amount dollars

Estimated total annual burden hours
I

20

I

3,461

$71.59

Total annual opportunity cost dollars

I

$247,773

We based this figure on average Lawyers hourly wages, as reported by Bureau of Labor Statistics data www.bls.gov/oes/current/oes231011.htm.
This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.

II. SSA submitted the information collections below to OMB for clearance.
Your comments regarding these information collections would be most useful if OMB and SSA receive them 30
days from the date of this publication.
To be sure we consider your comments, we must receive them no later than October 4, 2021. Individuals can obtain copies of these OMB clearance packages by writing to OR.Reports.Clearance@
ssa.gov.

Individuals who wish to withdraw their applications for benefits complete Form SSA521, or sign the completed form for each request to withdraw. SSA uses the information from Form SSA521 to process the request for withdrawal. The respondents are applicants for Retirement, Survivors, Disability, and Health Insurance benefits.

1. Request for Withdrawal of Application20 CFR 404.6400960
0015. Form SSA521, Request for Withdrawal of Application, allows claimants to specify which application they want to withdraw and the reason for the withdrawal. Form SSA521 is our preferred instrument for a withdrawal request; however, any written request for withdrawal signed by the claimant or a proper applicant on the claimants behalf will suffice.
Number of respondents
Modality of completion
Average burden per response minutes
Frequency of response
Type of Request: Revision of an OMBapproved information collection.
Average theoretical hourly cost amount dollars

Estimated total annual burden hours
Total annual opportunity cost dollars

Respondents applying for or receiving Retirement, Survivors, or Health Insurance benefits
Respondents applying for or receiving Disability benefits
60,753
14,374

1
1

5
5

5,063
1,198

$10.95
10.95

$55,440
13,118

Totals

75,127

6,261

68,558

We based this figure on the average DI payments based on SSAs current FY 2021 data https www.ssa.gov/legislation/2021FactSheet.pdf.
This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.

2. Statement of Employer20 CFR
404.801404.80309600030. When workers report they were paid wages but cannot provide proof of those earnings, and the wages do not appear in SSAs records of earnings, SSA uses Form SSA7011F4, Statement of Employer,
to document the alleged wages.
Specifically, the agency uses the form to resolve discrepancies in the individuals Social Security earnings record and to process claims for Social Security benefits. We only send Form SSA
7011F4 to employers if we are unable Number of respondents
Modality of completion
SSA7011F4

I

500

Average burden per response minutes
Frequency of response
I

1

I

30

able to locate the earnings information within our own records. The respondents are employers who can verify wage allegations made by wage earners.
Type of Request: Revision of an OMBapproved information collection.
Average theoretical hourly cost amount dollars

Estimated total annual burden hours
I

250

I

$27.07

Total annual opportunity cost dollars

I

$6,768

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We based this figure on average U.S. workers hourly wages, as reported by Bureau of Labor Statistics data https www.bls.gov/oes/current/oes_nat.htm000000.
This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.

3. Request for Workers Compensation/Public Disability Benefit Information20 CFR 404.408e0960
0098. Individuals who received both Social Security disability payments and Workers Compensation/Public Disability Benefits WC/PDB must notify SSA about their WC/PDB, so that
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the agency can reduce the claimants Social Security disability payments accordingly. Recipients may submit evidence of their WC/PDB, such as a copy of their award notice or benefit check, or have their WC/PDB provider complete Form SSA1709 to document their WC/PDB to SSA. The respondents
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are Federal, State, and local agencies, insurance carriers, and public or private self-insured companies administering WC/PDB benefits to disability recipients.
Type of Request: Revision of an OMBapproved information collection.

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