Addendum

OMB Change Sheet Addendum

SSA-3988-OCR-SM and SSA-3989-OCR-SM Statement for Determining Continuing

Eligibility Supplemental Security Income Payment

OMB 0960-0643

Collection Background

The Forms SSA-3988-OCR-SM and SSA-3989-OCR-SM are used exclusively for high probably of error profile (HEP) redeterminations. The forms have 21 and 20 questions respectively and are self-help, optical scanner forms. The information is used to determine whether SSI recipients have met and continue to meet all statutory and regulatory requirements for SSI eligibility and whether they have been and are still receiving the correct payment amount.

Reason for Change

The SS-3988 and SSA-3989 forms were first introduced to the public in FY06 as a self-help redetermination form that would clear through SSA systems with little or no human intervention. After reviewing several thousand of these cases, it was determined several minor changes/modifications to the forms would further enhance SSA’s ability to process these forms with little or no intervention from SSA employees and will make these forms a more efficient collection vehicle.

Revisions to the Collection Instrument

SSA plans to implement the changes to the collection instrument effective with the FY08 SSI redeterminations. Since this collection instrument is self-help, optical scanned form, it is mailed directly from a print contractor to the respondent. The contractor uses print specifications provided by SSA. SSA does not stock these forms; therefore, there is no stock or previous editions to destroy.

Following are changes SSA plans to make to the forms:

1. Minor format change to:

• Question 1. Move the “Single” block to the first line next to “Married NOT living with Spouse”. Many respondents were not able to quickly locate the “single” block and would erroneously check an incorrect block.

• Change the money amount blocks in questions 9, 11, and 13. Our review found that most respondents were not filling in whole dollars and were adding cents. Entries with cents instead of whole dollars were not scannable and required direct contact by the Data Operations Center to determine the exact money amount intended to be filled in by the respondent. By reducing the blocks from 5 to four and enlarging the coma, SSA feels correct responses will be received thus reducing the amount of direct contacts by the Data Operations Center.

• For Question 11a respondents would answer “Yes” and include Social Security, SSI or food stamps which required a direct contact from the Data Operations Center to verify the answer. Changing the parenthetical phrase to read, “(Do not include Social Security, SSI or Food Stamps)” will decrease ambiguous responses. This, in turn, will both increase the number of automatically processed cases and decrease direct contacts.

2. Breakout question 16 on SSA-3988 into five questions. Our review determined a breakout of question 16d into two questions (16d and 16e) would be easier for the respondents and would require less direct contact by the Data Operations Center.

• Question 16 will read as follows:

• 16a. Are you age 62 or older?

• 16b. If you are age 50 or older, are you a widow (er)?

• 16c. If you are age 50 or older and divorced, is your divorced spouse deceased?

• 16d. Were you disabled before age 22?

• 16e. Do you have a parent who is age 62 or older, disabled, or deceased?

3. Reword question 16 on SSA-3989 (child) to read:

• Does the Child have a parent who is age 62 or older, disabled, or deceased?

4. The current fugitive felon wording on questions 18 and 19 is obsolete. It is being replaced by OMB approved language. This language is used on all other SSI application/redetermination forms.

• Updated question 18 will read:

• Do you have any unsatisfied felony warrants for your arrest (Y/N)

• In which state or country was the warrant issued?

• Was the warrant satisfied (Y/N)

• Date warrant satisfied

• Updated question 19 will read:

• Do you have any unsatisfied Federal or State warrants for violating the conditions of probation or parole? (Y/N)

• In which state or country was the warrant issued?

• Was the warrant satisfied? (Y/N)

• Date warrant satisfied

5. On the last page of each form, we are changing the “For SSA Use only”
blocks. We have added two additional blocks: “FO Und” for Undeliverable and FO1 Dec” for Deceased. These new blocks allow the Data Operations Center employees to quickly annotate cases transferred to the FO jurisdiction because the respondent is deceased or the form was returned by the USPS as undeliverable and requires FO development of address.

6. Update the perjury statement on the signature page of both forms to reflect the current language found on other SSA forms. We will retain the first two sentences and replace the last two sentences with:

I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false or misleading statement about a material fact in this information, or causes someone else to do so, commits a crime and may be sent to prison, or may face other penalties, or both.

7. Update fact sheet for SSA-3988 and SSA-3989 to reflect current language found on other SSA forms regarding fugitive felons.  The last bullet on the facts sheets will be replaced with the following statement:

If you have any unsatisfied felony warrants for your arrest or if you have any unsatisfied Federal or State warrants for violating a condition of parole or probation.

Attached are mock-ups of the proposed changes.

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