Addendum to the Supporting Statement 0960-0004

ADDENDUM TO THE SUPPORTING STATEMENT

for Form SSA-10-BK & SSA-10-INST

Application for Widow’s or Widower’s Insurance Benefits & Instructions

20 CFR 404.335 – 404.338; 20 CFR 404.603

OMB NO. 0960-0004

Change 1: We are adding a sentence and informational link regarding this form.

(Old) N/A

(New)

For additional information about this application, a fact sheet to Form SSA-10 is available at www.socialsecurity.gov 

Justification 1: This was recommended by OMB and the same language above was used on the SSA-5 (0960-0003) and SSA-7(0960-0012) which were previously submitted and approved.

Change 2: We are changing the language in question #12 and #15 (marriage information).

12. (Old label and language) “Enter below the information requested about each marriage of the deceased, including marriage to you.

(New label language)

12. INFORMATION ABOUT THE DECEASED’S MARRIAGE(S)

Answer this item ONLY if the deceased had other marriages.

(a) If the deceased married after his or her marriage to you, enter the information on the last marriage. (If none, write “NONE”.)

.

Spouse’s Name (including maiden name)	When (Month, day, year)	Where (Name of City and State)
How Marriage Ended	When (Month, day, year)	Where (Name of City and State)
Marriage performed by: ___ Clergy or public official ___ Other (Explain in “Remarks”)	Spouse’s date of birth (or age)	If spouse deceased, give date of death
Spouse’s Social Security Number (If “None” or “Unknown”, so indicate)

(b) If the deceased had any other marriages, and the marriage lasted at least 10 years or ended due to death of the spouse (whether before or after you married the deceased), enter the information below. If the deceased divorced then remarried the same individual within the year immediately following the year of the divorce, and the combined period of marriage totaled 10 years or more, include the marriage. (If none, write “NONE”.)

Spouse’s Name (including maiden name)	When (Month, day, year)	Where (Name of City and State)
How Marriage Ended	When (Month, day, year)	Where (Name of City and State)
Marriage performed by: ___ Clergy or public official ___ Other (Explain in “Remarks”)	Spouse’s date of birth (or age)	If spouse deceased, give date of death
Spouse’s Social Security Number (If “None” or “Unknown”, so indicate)

(Use “Remarks” space on back of page for information about any other previous marriage as described in 12b.)

Change 3: We are changing question # 15 to reflect the format in which question # 12 has been changed.

15. (Old Language label) Enter below information about each of your marriages. Indicate your marriage to the deceased by entering deceased’s name (if you are applying for widower’s benefits, enter the maiden name if the deceased); it is not necessary to repeat other information about this marriage you have already given in item 12. Enter complete information on all other marriages, whether before of after you married the deceased.

(New label and language)

15. INFORMATION ABOUT YOUR MARRIAGE(S)

(a) Enter information about your marriage to the deceased.

Spouse’s Name (including maiden name)	When (Month, day, year)	Where (Name of City and State)
How Marriage Ended	When (Month, day, year)	Where (Name of City and State)
Marriage performed by: ___ Clergy or public official ___ Other (Explain in “Remarks”)	Spouse’s date of birth (or age)	Date of death

2. I f you remarried after the marriage shown in 15. (a), enter information about the last marriage. (If none, write “NONE”.)

Spouse’s Name (including maiden name)	When (Month, day, year)	Where (Name of City and State)
How Marriage Ended	When (Month, day, year)	Where (Name of City and State)
Marriage performed by: ___ Clergy or public official ___ Other (Explain in “Remarks”)	Spouse’s date of birth (or age)	If spouse deceased, give date of death
Spouse’s Social Security Number (If “None” or “Unknown”, so indicate)

( c) Enter information about any other marriage you may have had that lasted at least 10 years (see item 12(b) for counting consecutive multiple marriages to the same individual) or ended due to death of the spouse (whether before or after you married the deceased). If none, write “NONE”.

Spouse’s Name (including maiden name)	When (Month, day, year)	Where (Name of City and State)
How Marriage Ended	When (Month, day, year)	Where (Name of City and State)
Marriage performed by: ___ Clergy or public official ___ Other (Explain in “Remarks”)	Spouse’s date of birth (or age)	If spouse deceased, give date of death
Spouse’s Social Security Number (If “None” or “Unknown”, so indicate)

(Use “Remarks” space on back of page for information about any other previous marriage as described in 15c.)

Justification 2 & 3: We are modifying Question #12 and #15 to reflect marriage policy changes. Making this change will make the form consistent with policy and other applications which ask this question.

Change 4: We are changing the language and information under the title “Medicare Information”.

(Old language)

If this claim is approved and you are still entitled to benefits at age 65, you will automatically receive Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage at age 65. If you are not eligible for automatic enrollment in Medicare Part B, this application may be used for voluntary enrollment.

In most cases, Medicare does not pay for health care you get while traveling outside the United States. Your local Social Security office will be glad to explain more about Medicare.

Enrollment in Medicare Part B (Medical Insurance): Medicare Part B helps cover doctor's services and outpatient care. It also covers some other services that Medicare Part A doesn't cover. Once you are enrolled in Medicare Part B, you will have to pay a monthly premium. The date your Medicare Part B begins and the amount of the premium you must pay depends on the month you filed this application with the Social Security Administration. Your premiums will be deducted from any monthly Social Security, Railroad Retirement, or Office of Personnel Management benefit check you receive. If you do not receive such benefits, you will be notified how to pay your premiums. You will get advance notice if there is any change in your premium amount.

If you do not enroll in Medicare Part B now, you can enroll later only during a specified enrollment period. If you enroll later, your coverage may be delayed and you may have to pay a higher premium.

(New language)

MEDICARE INFORMATION

If this claim is approved and you are still entitled to benefits at age 65, or you are within 3 months of Age 65 or older you could automatically receive Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage at age 65. If you are not eligible for automatic enrollment in Medicare Part B, you will need to contact Social Security to request enrollment.

COMPLETE ITEM 23 ONLY IF YOU ARE WITHIN 3 MONTHS OF AGE 65 OR OLDER

Medicare Part B (Medical Insurance) helps cover doctor's services and outpatient care. It also covers some other services that Medicare Part A doesn't cover, such as some of the services of physical and occupational therapists and some home health care. If you enroll in Medicare Part B, you will have to pay a monthly premium. The amount of your premium will be determined when your coverage begins. In some cases, your premium may be higher based on information about your income we receive from the Internal Revenue Service.  Your premiums will be deducted from any monthly Social Security, Railroad Retirement, or Office of Personnel Management benefits you receive. If you do not receive any of these benefits, you will get a letter explaining how to pay your premiums. You will also get a letter if there is any change in the amount of your premium.

You can also enroll in a Medicare prescription drug plan (Part D). To learn more about the Medicare prescription drug plans and when you can enroll visit www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048) Medicare also can tell you about agencies in your area that can help you choose your prescription drug coverage.

If you have limited income and resources, we encourage you to apply for the Extra Help that is available to assist you with Medicare prescription drug costs. The Extra Help can pay the monthly premiums, annual deductibles and prescription co-payments. To learn more or apply, please visit www.socialsecurity.gov, call 1-800-772-1213 (TTY 1-900-325-0778) or visit the nearest Social Security office.

Justification 4: We are making this language change for clarification and the purpose of adding internet links regarding where individuals can find more information on-line.

Change 5: Remove the word “advantageous” from question #28 a. and b.

(Old language)

28.

I want benefits beginning with the earliest possible month that will be the most advantageous. I am full retirement age (or will be within 4 months) and I want benefits beginning with the earliest possible month that will be most advantageous, providing that there is no permanent reduction in my ongoing monthly benefits. (c) I want benefits beginning with . I understand that either a higher initial payment or a higher continuing monthly benefit amount may be possible, but I choose not to take it

(New language)

28

(a)I want benefits beginning with the earliest possible month. (b)I am full retirement age (or will be within 4 months) and I want benefits beginning with the earliest possible month, providing that there is no permanent reduction in my ongoing monthly benefits. (c) I want benefits beginning with . I understand that either a higher initial payment or a higher continuing monthly benefit amount may be possible, but I choose not to take it

Justification 5: The word “advantageous” is no longer being used per the financial literacy initiative which leaves it up to the individual to decide what is best for the financial situation when choosing a start date to benefits.

Change 6: We are removing question # 30 and # 31.

(Old questions)

30.	Do you have any unsatisfied felony warrants for your arrest?	Yes No
31.	Do you have any unsatisfied Federal or State warrants for your arrest for violating the conditions of your probation or parole?	Yes No

(New)

Delete question # 30 and # 31

Justification 6: Please delete questions 30 and 31 from the SSA-10-BK application. As part of SSA’s Ready Retirement initiative, the fugitive felon and parole and probation violation warrant questions have been eliminated from all Title II (Federal Old-Age, Survivors, and Disability Insurance Benefits) applications. The information regarding the reporting responsibilities should, however, remain on the "tear-off" sheet along with the other reporting responsibilities of the Title II claimant.

Change 7: We are moving the below paragraph from its present location on the SSA-10BK and adding the heading “WORK AND EARNINGS”.

CHANGES TO BE REPORTED AND HOW TO REPORT (Page 8 on SSA-10-BK)

For those under full retirement age, the law requires that a report of earnings be filed with SSA within 3 months and 15 days after the end of any taxable year in which you earn more than the annual exempt amount. You may contact SSA to file a report. Otherwise, SSA will use the earnings reported by your employer(s) and your self-employment tax return (if applicable) as the report of earnings required by law and adjust benefits under the earnings test. It is your responsibility to ensure that the information you give concerning your earnings is correct. You must furnish additional information as needed when your benefit adjustment is not correct based on the earnings on your record.

Justification 7: The paragraph above is listed under the caption “Changes to be Reported and How to Report”. This paragraph needs to repositioned under the caption “WORK AND EARNINGS”. Having this paragraph located in its current location does not relate to the caption.

Change 8: Reporting Responsibilities for Widow’s or Widower’s Insurance Benefits (SSA-10-INST)

Insert new heading “Work and Earnings” under heading “How To Report”

Relocate the paragraph below to under the new heading “Work and Earnings.”

For those under full retirement age, the law requires that a report of earnings be filed with SSA within 3 months and 15 days after the end of any taxable year in which you earn more than the annual exempt amount. You may contact SSA to file a report. Otherwise, SSA will use the earnings reported by your employer(s) and your self-employment tax return (if applicable) as the report of earnings required by law and adjust benefits under the earnings test. It is your responsibility to ensure that the information you give concerning your earnings is correct. You must furnish additional information as needed when your benefit adjustment is not correct based on the earnings on your record.

Justification 8: To be consistant with format on Form SSA-10-BK

Other revisions to the collection instrument: We are revising the PRA statement to reflect our current boilerplate language.  The current language, which dates back to the last reprint of the form and instructions, is outdated.

SSA’s Office of the General Counsel is conducting a systematic review of SSA’s Privacy Act Statements on agency forms. As a result, SSA is updating the Privacy Act Statement on the form and the instructions.