Addendum to Supporting Statement

Addendum to Supporting Statement for Form SSA-4111

Certificate of Election for Reduced Widow(er)’s and Surviving

Divorced Spouse’s Benefits

20 CFR 404.335

OMB No. 0960-0759

Minor Revisions to the Collection Instrument

The Social Security Administration (SSA) uses Form SSA-4111 to pay a qualified dually entitled widow(er) (or surviving divorced spouse) who elects to receive a reduced widow(er) benefit. Currently, the respondent can complete Form SSA‑4111 and mail it back to SSA, or an SSA employee can fill out the form over the phone or through a face‑to-face interview. At this time, claimants must print the blank PDF and fill it out using a pen, or they need to use a typewriter to complete the form. As some handwriting is difficult to read, or illegible, these non-fillable versions of the form are inefficient and ineffective since SSA employees who cannot read the submitted form must re-contact the respondent prior to processing. In addition, the use of typewriters decreased significantly, as other tools, such as personal computing devices, increase in use.

SSA developed a fillable, printable version of the SSA-4111, as some individuals may find it easier to use. The fillable version allows the respondents to complete the form electronically using a personal computer, or other computing device, print the completed form, and submit it to SSA. We developed this fillable version, as we want to ensure SSA provides effective communication and remains in compliance with the requirements of 45 CFR 85.51 of the Code of Federal Regulations and section 504 of the Rehabilitation Act of 1973. We propose the fillable PDF version as a more accessible modality. In addition, the new fillable modality will enhance our electronic services and recordkeeping efforts.

Revisions to the Information Collection

• Change #1: SSA intends to provide Form SSA-4111 in a fillable PDF file on our website, in place of the non-fillable PDF version we currently provide. We propose to make all form entries fillable.

Justification #1: This change will allow the respondents to continue to print and complete the form by hand, or, alternatively, complete the form using a computing device, such as a personal computer or handheld (mobile) device, print, and submit the form to SSA for processing.

• Change #2: We are revising the Privacy Act Statement on this form.

Justification #2: 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.

After OMB approves the addition of the new fillable version of the form, SSA will phase out the standard PDF versions from our Internet and Intranet websites and replace them with the fillable PDF file.

This action does not affect the public reporting burden.