Addendum to Supporting Statement 0004

Addendum to the Supporting Statement for the SSA-10-BK

Application for Widow’s or Widower’s Insurance Benefits

20 CFR 404.335 – 404.338, and 404.603

OMB No. 0960-0004

Revisions to the Collection Instrument – Form SSA-10-BK

• Change 1: Page 1: Question number 6(c), we revised the language as follows:

From:

“Check this Block.”

To:

“Check this Box”

Justification 1: We revised the language in this question to provide consistency with Question number 6(a).

• Change 2: Page 2: Top of page, we will move instructions to left margin:

From:

ANSWER ITEM 9 ONLY IF DEATH OCCURRED WITHIN THE LAST 2 YEARS.

To:

ANSWER ITEM 9 ONLY IF DEATH OCCURRED WITHIN THE LAST 2 YEARS.

Justification 2: We moved the sentence to the left margin for consistency with other instructions.

• Change 3: Page 2: Question number 12(a), we will bold the following sentence:

From:

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

To:

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

Justification 3: We made this change to emphasize when to add the word “None.”

• Change 4: Page 2: Bottom of page, we need to add a period at the end of the sentence:

From:

USE "REMARKS" SPACE ON BACK PAGE FOR INFORMATION ABOUT ANY OTHER PREVIOUS MARRIAGE AS DESCRIBED IN 12b

To:

USE "REMARKS" SPACE ON BACK PAGE FOR INFORMATION ABOUT ANY OTHER PREVIOUS MARRIAGE AS DESCRIBED IN 12b.

Justification 4: We edited the sentence to add a period at the end of the sentence.

• Change 5: Page 3: Question number 15 (c), we revised the sentence:

From:

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"

To:

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".)

Justification 5: We added a period at the end of the second sentence beginning “If none….” We also enclosed in parentheses “If none, write NONE” for consistency with other instructions.

• Change 6: Page 3: Instructions above Question 16, we will bold the language:

From:

IF YOU ARE APPLYING FOR SURVIVING DIVORCED SPOUSE'S BENEFITS, OMIT 16 AND GO ON TO ITEM 17.

To:

IF YOU ARE APPLYING FOR SURVIVING DIVORCED SPOUSE'S BENEFITS, OMIT 16 AND GO ON TO ITEM 17.

Justification 6: We made these changes to bold the language for consistency with other instructions on the form.

• Change 7: Page 4: Last paragraph under heading: COMPLETE ITEM 23 ONLY IF YOU ARE WITHIN 3 MONTHS OF AGE 65 OR OLDER. We need to remove the extra space between the words “can” and “pay”:

From:

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:

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 7: We edited the sentence to remove the extra space between the words “can” and “pay.”

• Change 8: Page 5: Top of Page, we will move heading instructions to the left margin:

From:

ANSWER ITEM 24 ONLY IF THE DECEASED DIED BEFORE THIS YEAR.

To:

ANSWER ITEM 24 ONLY IF THE DECEASED DIED BEFORE THIS YEAR.

Justification 8: We moved the heading instructions to the left margin for consistency with the other heading instructions on the form.

• Change 9: Page 5: Third set of heading instructions, we are correcting a misspelled word:

From:

IF YOU ARE FULL RETIREMENT AGE OR OLDER, GO ON TO PAGE 6. OTHERWISE, PLEASE READ CAREFULLY THE INFORMAITON ON PAGE 8 AND ANSWER ONE OF THE FOLLOWING ITEMS. m:

To:

IF YOU ARE FULL RETIREMENT AGE OR OLDER, GO ON TO PAGE 6. OTHERWISE, PLEASE READ CAREFULLY THE INFORMATION ON PAGE 8 AND ANSWER ONE OF THE FOLLOWING ITEMS.

Justification 9: We corrected the spelling of the word “information.”

• Change 10: Page 5: Bottom of Page, we will move heading instructions to the left margin:

From:

ANSWER QUESTION 29 ONLY IF YOU ARE NOW AT LEAST AGE 61 YEARS, 8 MONTHS.

To:

ANSWER QUESTION 29 ONLY IF YOU ARE NOW AT LEAST AGE 61 YEARS, 8 MONTHS.

Justification 10: We moved the heading instructions to the left margin for consistency with the other heading instructions on the form.

Change 11: Page 6: Under “Signature of Applicant,” we will bold the statement “Write in ink”:

From:

Signature (First name, middle initial, last name) (Write in ink)

To:

Signature (First name, middle initial, last name) (Write in ink)

Justification 11: We bolded the statement to emphasize the instruction to use ink.

• Change 12: Page 8, first sentence, we need to add a period at the end of the sentence:

From:

FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT MUST BE REPAID, AND IN POSSIBLE MONETARY PENALTIES

To:

FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT MUST BE REPAID, AND IN POSSIBLE MONETARY PENALTIES.

Justification 12: We edited the sentence to add a period at the end of the sentence.

• Change 13: Page 8: Column 1, bullet 1 and bullet 6, we need to add a space between the text and bullet.

Justification 13: We edited the column 1 and column 2 to create a space between the bullet and the text.

• Change 14: Page 8: bullet 9, Changes to be Reported and How to Report, we changed 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 your pension or annuity amount changes.

To:

You begin to receive a pension, annuity, or a lump sum payment based on your government employment not covered by Social Security or your pension or annuity amount changes or stops.

Justification 14: We revised this statement for the following reason: the revisions to the SSA-10 correspond with the same reporting responsibility language as in both MCS and the iClaim. In addition, the requested revisions to the SSA-10 are consistent with a prior request to change the same reporting responsibilities on the SSA-2 Application for Wife’s or Husband’s Insurance Benefits as related to the GPO provision.

• Change 15: Page 8: Bullet 10, Changes to be Reported and How to Report, we revised the language:

From:

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.

To:

You have an unsatisfied warrant for more than 30 continuous days for your arrest for a crime or attempted crime that is a felony or flight to avoid prosecution or confinement, escape from custody, and flight-escape. In most jurisdictions that do not classify crimes as felonies, this applies to a crime that is punishable by death or imprisonment for a term exceeding 1 year (regardless of the actual sentence imposed).

Justification 15: This change is necessary because of the Martinez Settlement that caused Social Security to no longer suspend benefits for an outstanding felony warrant unless the warrant was issued for a crime or attempted crime of flight to avoid prosecution or confinement, escape from custody and flight-escape. We also added “more than 30 continuous days” because the Social Security Act specifically sates this for Title II prisoner and fugitive felon suspensions. The revision reflects the changes of other recently updated and approved forms in a similar format (e.g., SSA-5).

• Change 16: Page 8: Column 2, bullet 1, Changes to be Reported and How to Report, we deleted the bullet:

You are violating a condition of probation or parole imposed under Federal or State law.

Justification 16: We need to delete this entire bullet. On August 4, 2015, our Policy Office’s Associate Commissioner decided we would no longer suspend benefits or stop payments to Title II beneficiaries and Title XVI recipients if the beneficiary or recipient alleged having an unsatisfied violation of probation or parole under Federal or State law. Our Policy Office decided we would no longer enforce the probation or parole violation non‑payment sections of the Social Security Act because the statute, as currently constructed, is flawed and not susceptible to implement given the restrictions place on the Agency by the Clark Court Order.

• Change 17: Page 8: under the heading How to Report, we updated the sentence to remove semi-colon and add period:

From:

For general information about Social Security, visit our web site at www.socialsecurity.gov;

To:

For general information about Social Security, visit our web site at www.socialsecurity.gov.

Justification 17: We edited the sentence to remove the semi-colon and add a period.

• Change 18: Page 8: under the heading, Figuring Your Annual Earnings, we revised the sentence:

From:

This includes earnings both before and after retirement, and applies to all earned income whether or not covered by Social Security.

To:

This includes earnings both before and after your retirement date, and applies to all earned income whether or not covered by Social Security.

Justification 18: We revised the sentence to provide clarity.

Revisions to the Collection Instrument – Form SSA-10-INST

• Change 19: Page 1: 1st bullet, right column, “Reporting Responsibilities for Widow’s or Widower’s Insurance Benefits,” we revised the language:

From:

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.

To:

You begin to receive a pension, annuity, or a lump sum payment based on your government employment not covered by Social Security or your pension or annuity amount changes or stops.

Justification 19: We revised this statement for the following reason: the revisions to the SSA-10 correspond with the same reporting responsibility language as in both MCS and the iClaim. In addition, the requested revisions to the SSA-10 are consistent with a prior request to change the same reporting responsibilities on the SSA-2 Application for Wife’s or Husband’s Insurance Benefits as related to the GPO provision.

• Change 20: Page 1: 2nd bullet, right column, “Reporting Responsibilities for Widow’s or Widower’s Insurance Benefits,” we revised the language:

From:

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.

To:

You have an unsatisfied warrant for more than 30 continuous days for your arrest for a crime or attempted crime that is a felony or flight to avoid prosecution or confinement, escape from custody, and flight-escape. In most jurisdictions that do not classify crimes as felonies, this applies to a crime that is punishable by death or imprisonment for a term exceeding 1 year (regardless of the actual sentence imposed).

Justification 20: This change is necessary because of the Martinez Settlement that caused Social Security to no longer suspend benefits for an outstanding felony warrant unless the warrant was issued for a crime or attempted crime of flight to avoid prosecution or confinement, escape from custody and flight-escape. We also added “more than 30 continuous days” because the Social Security Act specifically sates this for Title II prisoner and fugitive felon suspensions. The revision reflects the changes of other recently updated and approved forms in a similar format (e.g., SSA-5).

• Change 21: Page 1: 3rd bullet, right column, “Reporting Responsibilities for Widow’s or Widower’s Insurance Benefits,” we deleted the bullet:

You are violating a condition of probation or parole imposed under Federal or State law.

Justification 21: We need to delete this entire bullet. On August 4, 2015, our Policy Office Associate Commissioner decided we would no longer suspend benefits or stop payments to Title II beneficiaries and Title XVI recipients if the beneficiary or recipient alleged having an unsatisfied violation of probation or parole under Federal or State law. Our Policy Office decided we would no longer enforce the probation or parole violation non-payment sections of the Social Security Act because the statute, as currently constructed, is flawed and not susceptible to implement given the restrictions place on the Agency by the Clark Court Order.

Revisions to the Collection Instruments – Forms SSA-10-BK and SSA-10-INST

• Change 22: We are revising the PRA statement on this form.

Justification 22: 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, is now outdated.

• Change 23: We are revising the Privacy Act Statement on this form.

Justification 23: 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.

We will start using the new version immediately after OMB approval. We will destroy stocks of the old version.