Addendum To Supporting Statement

ADDENDUM TO SUPPORTING STATEMENT

Revision to the Collection Instrument

SSA needs to revise Section 3 (the bottom part) on page 8 (last page of SSA-3369) to eliminate collecting duplicate information. In most cases, the applicant completing the form is the disabled individual. Since the form is printed every 6 months, SSA will continue to use the current SSA-3369 until stock is depleted.

SSA-3369 – Current page 8

Name of person completing this form (Please print)	Date (Month, day year)
Address (Number and Street)	Email address (optional)
City	S tate Zip Code

Form SSA-3369-BK (1-2005) ef (01-2006) PAGE 8

SSA-3369 – Revised page 8

N ame of person completing this form (Please print) Date Form Completed (Month, day, year)

E-Mail Address of person completing this form (optional)

If the person completing this form is other than the disabled person, please complete the following information.

R elationship to Disabled Person Daytime Telephone Number

A ddress (Number and street) City State Zip Code