SSI Notice of Interim Assistance Reimbursement (IAR)

Forms and Documents

Document Name	Status
Form SSA-L8125-F6 e) Paper Form SSA-L8125-F6 Form and Instruction	Modified
Addendum 0546.doc Supplementary Document	2017-08-02
Supporting Statement 0546 (revised).doc Supporting Statement A	2017-08-02

IC Document Collections

IC ID	Document Title	Status
9467	a) State Notification of Receipt of Authorization (Electronic Process) Other-Internet Screens	Modified
186519	m) Correct Administrative and Accounting Discrepancies	Unchanged
186518	l) Participate in Periodic Review	Unchanged
186517	k) Retrieve and Consolidate Authorization and Accounting Forms	Unchanged
186516	j) Written Notice from State to Recipient Regarding Amount of Payment	Unchanged
186515	i) Maintenance of Accounting Forms and Notices	Unchanged
186514	h) Maintenance of Authorization Forms	Unchanged
186513	g) Review/Signing Agreements	Unchanged
186512	f) State Notification to SSA of Deceased Claimant	Unchanged
186510	e) Paper Form SSA-L8125-F6 Form and Instruction	Modified
186508	d) State Request for Determination--Dispute Resolution	Unchanged
186507	c) State Notification to SSA of Amount of Reimbursement	Unchanged
186506	b) State Submission of Copy of Authorization (Manual Process)	Unchanged

ICR Details

OMB Control No: 0960-0546	ICR Reference No: 201703-0960-019
Status: Active	Previous ICR Reference No: 201406-0960-004
Agency/Subagency: SSA	Agency Tracking No:
Title: SSI Notice of Interim Assistance Reimbursement (IAR)
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: 10/27/2017
	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	10/31/2020	36 Months From Approved	10/31/2017
Responses	637,160	0	637,160
Time Burden (Hours)	45,216	0	45,216
Cost Burden (Dollars)	0	0	0

---

Abstract: Section 1631(g) of the Act authorizes SSA to reimburse an IAR agency from an individual's retroactive Supplemental Security Income (SSI) payment for assistance the IAR agency gave the individual for meeting basic needs while an SSI claim was pending or SSI payments were suspended or terminated. The State or local agency needs an IAR agreement with SSA to participate in the IAR program. The individual receiving the IAR payment signs an authorization form with an IAR agency to allow SSA to repay the IAR agency for funds paid in advance prior to SSA's determination on the individual's claim. The authorization represents the individual's intent to file for SSI, if they did not file an application prior to SSA receiving the authorization. Agencies who wish to enter into an IAR agreement with SSA needs to meet the following requirements: (a) Reporting Requirements - Each IAR agency agrees to: (1) Notify SSA of receipt of an authorization for initial claims or cases they are appealing, and submit a copy of that authorization either through a manual or electronic process; (2) inform SSA of the amount of reimbursement; (3) submit a written request for dispute resolution on a determination; (4) notify SSA of interim assistance paid (using the SSA–L8125–F6); (5) inform SSA of any deceased claimants who participate in the IAR program and ; (6) review and sign an agreement with SSA. (b) Recordkeeping Requirements - The IAR agencies agree to retain all notices, agreement, authorizations, and accounting forms for the period defined in the IAR agreement for the purposes of SSA verifying transactions covered under the agreement. (c) Third Party Disclosure Requirements: Each participating IAR agency agrees to send written notices from the IAR agency to the recipient regarding payment amounts and appeal rights. (d) Periodic Review of Agency Accounting Process - The IAR agency makes the IAR accounting records of paid cases available for SSA review and verification. SSA conducts reviews either onsite or through the mail of the authorization forms, notices to the claimant and accounting forms. Upon completion of the review, SSA provides a written report of findings to the IAR agency director. The respondents are State IAR officers.

---

Authorizing Statute(s): None

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 21291	05/05/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 35022	07/27/2017
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 13

IC Title	Form No.	Form Name
e) Paper Form SSA-L8125-F6	SSA-L8125-F6	Supplemental Security Income Notice of Interim Assistance Reimbursement
g) Review/Signing Agreements
c) State Notification to SSA of Amount of Reimbursement
d) State Request for Determination--Dispute Resolution
f) State Notification to SSA of Deceased Claimant
i) Maintenance of Accounting Forms and Notices
a) State Notification of Receipt of Authorization (Electronic Process)
b) State Submission of Copy of Authorization (Manual Process)
j) Written Notice from State to Recipient Regarding Amount of Payment
m) Correct Administrative and Accounting Discrepancies
h) Maintenance of Authorization Forms
l) Participate in Periodic Review
k) Retrieve and Consolidate Authorization and Accounting Forms

---

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	637,160	637,160	0	0	0	0
Annual Time Burden (Hours)	45,216	45,216	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:

---

Annual Cost to Federal Government: $0

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

---

Common Form ICR:  No

---

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

---