Justification for the Non-Substantive Changes for OMB # 0960-0101

Justification for Non-Substantive Changes for SSA-1724-F4

Claim for Amounts Due In The Case of a Deceased Beneficiary

20 CFR 404.503(b)

Section 1870(g) of the Social Security Act

OMB No. 0960-0101

Revisions to the Collection Instrument

We were unable to make these changes prior to the previous clearance package submission, because when we determined changes were necessary, we had already submitted the form for renewal:

• Change #1: We are changing the title of the form from “Claim for Amounts Due In The Case of a Deceased Social Security Recipient” to “Claim for Amounts Due In The Case of a Deceased Beneficiary”.

Justification #1: We are making this change to generalize the form so that we can use it for both Title II underpayments and Title XVIII Medicare premium refunds.

• Change #2: We are adding wording in the first bold paragraph to include, “and/or Medicare premium refund” and will delete, “at the time of death.”

Justification #2: Since we will use this form for both Title II underpayments and Title XVIII Medicare premium refunds, we are removing “at the time of death” as underpayments may be due to next of kin or legal representative for an activity that occurred before the beneficiary died.

• Change #3: We are deleting the text “from the Social Security Administration” immediately below the first bolded paragraph.

Justification #3: We are making this change to generalize the form so that we can use it for both Title II underpayments and Title XVIII Medicare premium refunds.

We will implement these changes immediately upon OMB approval.