Justification for Non-Substantive Change -- 0960-0696

0960-0695 (Form SSA-1021)

Justification for Non-Substantive Changes

We are making several minor changes to form SSA-1021 (see below):

Change 1:

We added the button SSA seal and the swish.

Justification 1:

This change is necessary to keep form SSA-1021 consistent with the appearance of related form SSA-1020 (OMB No. 0960-0696).

Change 2:

We added the word "Extra" in the title of the form, as in:

Appeal of Determination for Extra Help with Medicare Prescription Drug Plan Costs

Justification 2:

Addition of this word is necessary to keep the Form SSA-1021 consistent with the title of Form SSA-1020.

Change 3:

We added the following statement to the Signature block:

By submitting this appeal, I am authorizing SSA to obtain and disclose information related to my income, resources, and assets, foreign and domestic, consistent with applicable privacy laws. This information may include, but is not limited to, information about my wages, account balances, investments, benefits, and pensions.

Justification 3:

The addition of these two statements is necessary to keep Form SSA-1021 consistent with Form SSA-1020.

Change 4:

We added the following statement to the Privacy Act section:

We may also need to share the information with other SSA programs if SSA needs to determine your eligibility in those programs.

Justification 4:

The addition of these two statements is necessary to keep form SSA-1021 consistent with form SSA-1020.