20 CFR 404.335 – 404.338, and 404.603
OMB No. 0960-0004
Revision to the Collection Instrument – Form SSA-10-BK
Change 1: Application information section, directly under the title: We changed the language.
From:
“I apply for all insurance benefits for which I am eligible under Title II (Federal Old-Age, Survivors, and Disability Insurance) and Part A of Title XVIII (Health Insurance for the Aged and Disabled) of the Social Security Act, as presently amended. The information you furnish on this application will ordinarily be sufficient for a determination of the lump-sum death payment.
* This may also be considered an application for survivors benefits under the Railroad retirement Act and for Veterans Administration payments under title 38 U.S.C., Veterans Benefits, Chapter 13 (which is, as such, an application for other types of death benefits under title 38). If you were receiving benefits as a wife/husband at the time of your spouse’s death, you only need to complete the circled items. All other claimants must complete the entire form. For additional information about this application a fact sheet to Form SSA-10-BK is available at www.socialsecurity.gov.”
To:
“With this application, you are applying for all insurance benefits for which you are eligible under Title II (Federal Old-Age, Survivors, and Disability Insurance) and Part A of Title XVIII (Health Insurance for the Aged and Disabled) of the Social Security Act as presently amended. The information you furnish on this application will ordinarily be sufficient for a determination on the lump-sum death payment.
If you were receiving spouse’s benefits at the time of your spouse’s death, you only need to complete the circled items. All other claimants must complete the entire form.
*This may also be considered an application for survivors benefits under the Railroad retirement Act and for Veterans Administration payments under title 38 U.S.C., Veterans Benefits, Chapter 13 (which is, as such, an application for other types of death benefits under title 38).”
Justification 1: We revised this statement for the following reasons: (1) to fix the grammar – the current statement is a mix of first person and third person language; (2) to list pertinent information first; (3) to remove a reference to a fact sheet that no longer exists; and (4) to increase ease of reading.
Change 2: Question 17(a), page 3: We changed the language.
From:
“Have you (or has someone on your behalf) ever filed an application for Social Security benefits, a period of disability under Social Security, supplemental security income, or hospital or medical insurance under Medicare?”
To:
“Have you (or has someone on your behalf) ever filed an application for Social Security benefits, a period of disability under Social Security, Supplemental Security Income, or hospital or medical insurance under Medicare?”
Justification 2: We changed this language to capitalize “Supplemental Security Income” because it is a proper noun.
Change 3: Question 22(a), page 4: We revised the language.
From:
“Have you qualified for, or do you expect to qualify for, a pension or annuity (or a lump sum in place of a pension or annuity) based on your own employment and earnings for the Federal Government of the United States, or one of its States or local subdivisions? (Social Security benefits are not government pensions.)”
To:
“Have you qualified for, or do you expect to qualify for, a pension or annuity (or a lump sum in place of a pension or annuity) based on your own employment and earnings for the Federal Government of the United States, or one of its States or local subdivisions that was not covered under Social Security? (Social Security benefits are not government pensions.)”
Justification 3: This revision corresponds with the same question(s) we ask in both the Modernized Claims System (MCS) and iClaim (OMB # 0960-0618). For the widow(er) application in both MCS and iClaim, we ask if the applicant ever worked or is qualified, or entitled, to receive a pension or annuity for employment not covered under Social Security.
Change 4: Medicare Information, page 4 (bottom) : We revised the language
From:
“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 1-800-325-0778) or visit the nearest Social Security office.”
To:
“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 live in Puerto Rico or a foreign country, you are not eligible for automatic enrollment in Medicare Part B, and 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. The amount of your premium varies based on the prescription drug plan provider. The amount you pay for Part D coverage may be higher than the listed plan premium, based on information about your income we receive from the Internal Revenue Service.
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 1-800-325-0778) or visit the nearest Social Security office.”
Justification 4: We revised the language in this section because the current application does not accurately reflect the statute-driven requirement stating residents of Puerto Rico and those who reside outside the U.S. must actively enroll in Medicare Part B, as we do not automatically enroll them in Part B. In addition, the application form predates the extension of income-related monthly adjustments (IRMAA) to Medicare prescription drug coverage (Medicare Part D), which we implemented in 2011. Since we mention IRMAA for Part B, full disclosure includes mentioning IRMAA for Part D.
Change 5: The last sentence in questions 24(b), 25(b), and 26(b), page 5: We changed the language in this sentence for all three questions.
From:
“*Enter the appropriate monthly limit after reading the instructions, “How Your Earnings Affect Your Benefits.”
To:
“*Enter the appropriate monthly limit after reading the information in “How Work Affects Your Benefits.”
Justification 5: We revised the language in these sentences both because it was grammatically incorrect and because we changed the name of the publication.
Change 6: Page 6: We moved the direct deposit section directly above the penalty clause, and changed the information required to complete the question.
From:
“Routing Transit Number” “C/S,” “Depositor Account Number,” “No Account,” “Direct Deposit Refused.”
To:
“Routing Transit Number,” “Account Number,” “Checking,” “Savings,” “Enroll in Direct Express,” and “Direct Deposit Refused.”
Justification 6: We revised the language in this question to make it a self-help question. We moved the location of the question to include the applicant’s answers under the penalty clause.
Change 7: 6th bullet, left column, “Changes to Be reported and How To Report,” page 8: We revised the language.
From:
“Change of Marital Status—Marriage, divorce, annulment of marriage. You must report a marriage even if you believe that an exception applies.”
To:
“Change of Marital Status—Marriage, divorce, annulment of marriage. You must report a change in marital status even if you believe that an exception applies.”
Justification 7: We revised this language because the original language only stated the need for respondents to report a marriage, while we require respondents to report any change in marital status.
Change 8: 7th bullet, left column, “Changes to Be reported and How To Report,” page 8: We revised the language.
From:
“You are confined to jail, prison, penal institution or correctional facility for conviction of a crime or you are confined to a public institution by court order in connection with a crime”
To:
“You are confined for more than 30 continuous days to jail, prison, penal institution, or correctional facility for conviction of a crime or you are confined to a public institution by court order in connection with a crime.”
Justification 8: We made these changes because the Social Security Act specifically adds the language “more than 30 continuous days” for title II prisoner and fugitive felon suspensions.
Change 9: Bottom of page 7: we revised the Privacy Act Statement.
Justification 9: 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.
Change 10: 10th bullet, left column, “Changes to Be reported and How To Report,” page 8: We revised the language.
From:
“You have an unsatisfied warrant for your arrest for a crime or attempted crime that is a felony (or, in jurisdictions that do not define crimes as felonies, a crime that is punishable by death or imprisonment for a term exceeding 1 year.)”
To:
“You have an unsatisfied arrest warrant for more than 30 continuous days for flight to avoid prosecution or confinement, escape from custody, or flight-escape.”
Justification 10: We made these changes because the Social Security Act specifically adds the language “more than 30 continuous days” for title II prisoner and fugitive felon suspensions. In addition, we now require this information for suspension of title II benefits for a felony warrant because of the Martinez Court Case and for probation and parole based on the Clark Court Order.
Change 11: 1st bullet, right column, “Changes to Be reported and How To Report,” page 8: We revised the language.
From:
“You have an unsatisfied warrant for a violation of probation or parole under Federal or State law.”
To:
“You are violating a condition of probation or parole imposed under Federal or State law.”
Justification 11: We made these changes because we now require this information for suspension of title II benefits for a felony warrant because of the Martinez Court Case and for probation and parole based on the Clark Court Order.
Change 12: Section entitled “Changes to Be reported and How To Report,” in the “How to Report,” section, page 8: We changed the first sentence.
From:
“You can make your reports by telephone, mail, or in person, whichever you prefer.”
To:
“You can make your reports by telephone, mail, in person, or online, whichever you prefer.”
Justification 12: We added information to show claimants can make changes through our website.
Change 13: Section entitled “Changes to Be reported and How To Report,” in the “How to Report,” section, page 8: We added an additional bullet that reads:
“Visiting the section “What You Can Do Online” at our web site at www.socialsecurity.gov;”
Justification 13: We added this bullet to promote the use of our online services.
Change 14: Bottom of page 8, 3rd sentence in the section entitled “Please Read The Following Information Carefully Before Answering Question 28”: We changed the language.
From:
“(For the appropriate exempt amount, see “How Your Earnings Affect your Benefits.”)”
To:
“(For the appropriate exempt amount, see “How Work Affects your Benefits.”)”
Justification 14: We revised this language because we changed the name of the publication.
Revision to the Collection Instrument – Form SSA-10-INST
Change 1: 6th bullet, left column, “Reporting Responsibilities for Widow’s or Widower’s Insurance Benefits,” page 1: We revised the language.
From:
“Change of Marital Status—Marriage, divorce, annulment of marriage. You must report a marriage even if you believe that an exception applies.”
To:
“Change of Marital Status—Marriage, divorce, annulment of marriage. You must report a change in marital status even if you believe that an exception applies.”
Justification 1: We revised this language because the original language only stated the need for respondents to report a marriage, while we require respondents to report any change in marital status.
Change 2: 8th bullet, left column, “Reporting Responsibilities for Widow’s or Widower’s Insurance Benefits,” page 1: We revised the language.
From:
“You are confined to jail, prison, penal institution or correctional facility for conviction of a crime or you are confined to a public institution by court order in connection with a crime.”
To:
“You are confined for more than 30 continuous days to jail, prison, penal institution, or correctional facility for conviction of a crime or you are confined to a public institution by court order in connection with a crime.”
Justification 2: We made these changes because the Social Security Act specifically adds the language “more than 30 continuous days” for title II prisoner and fugitive felon suspensions.
Change 3: 1st bullet, right column, “Reporting Responsibilities for Widow’s or Widower’s Insurance Benefits,” page 1: We revised the language.
From:
“You begin to receive a government pension or annuity (from the Federal government or any State or any political subdivision thereof) or you pension or annuity amount changes.”
To:
“You begin to receive a government pension or annuity (from the Federal government or any State or local subdivision thereof) based on your own employment and earnings that was not covered under Social Security, or your pension or annuity amount changes.”
Justification 3: We made this change to clarify that beneficiaries only need to report pensions resulting from non-covered earnings.
Change 4: 2nd bullet, right column, “Reporting Responsibilities for Widow’s or Widower’s Insurance Benefits,” page 1: We revised the language.
From:
“You have an unsatisfied warrant for your arrest for a crime or attempted crime that is a felony (or, in jurisdictions that do not define crimes as felonies, a crime that is punishable by death or imprisonment for a term exceeding 1 year.)”
To:
“You have an unsatisfied arrest warrant for more than 30 continuous days for flight to avoid prosecution or confinement, escape from custody, or flight-escape.”
Justification 4: We made these changes because the Social Security Act specifically adds the language “more than 30 continuous days” for title II prisoner and fugitive felon suspensions, and we now require this information for suspension of title II benefits for a felony warrant because of the Martinez Court Case and for probation and parole based on the Clark Court Order.
Change 5: 3rd bullet, right column, “Reporting Responsibilities for Widow’s or Widower’s Insurance Benefits,” page 1: We revised the language.
From:
“You have an unsatisfied warrant for a violation of probation or parole under Federal or State law.”
To:
“You are violating a condition of probation or parole imposed under Federal or State law.”
Justification 5: We now require this information for suspension of title II benefits for a felony warrant because of the Martinez Court Case and for probation and parole based on the Clark Court Order.
Change 6: Section entitled “Changes to Be reported and How To Report,” “How to Report,” page 8: We changed the first sentence.
From:
“You can make your reports by telephone, mail, or in person, whichever you prefer.”
To:
“You can make your reports by telephone, mail, in person, or online, whichever you prefer.”
Justification 6: We added information to show claimants can make changes through our website.
Change 7: Section entitled “Changes to Be reported and How To Report,” “How to Report,” page 1: We added an additional bullet that reads:
“Visiting the section “What You Can Do Online” at our web site at www.socialsecurity.gov;”
Justification 7: We added this bullet to promote the use of our online services.
Change 8: Section entitled “Notice About Documents,” page 1: We revised the first sentence.
From: “We recommend that you keep all documents you submitted to us.”
To: “We recommend that you keep copies of all documents you submitted to us.”
Justification 8: We revised this sentence for clarity purposes.
We will start using the new version immediately after OMB approval.
We will destroy stocks of the old version.
| File Type | application/msword |
| Author | 889123 |
| Last Modified By | Naomi |
| File Modified | 2012-12-07 |
| File Created | 2012-11-07 |