Addendum - 0759

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

Revisions to the Information Collection

• Change #1: Under “Enter Your Social Security Number,” we are removing (If “none” or “unknown” so indicate.)

Justification #1: We require individuals to provide an SSN.

• Change #2: Under “Information On How Benefits Are Affected….,” we are replacing the word “election” with “selection” in the last sentence of the paragraph.

Justification #2: We will use the word “selection” for consistency.

• Change #3: We are updating the paragraph under number 3 to read:

The selected month can be the month the deceased worker died or any month before you reach FRA (provided that the month you choose is within the past 12 months).

Justification #3: We are changing the language for clarification purposes.

• Change #4: Under the address block, we are deleting “Enter the Name of County (if any) in which you live now.”

Justification #4: There is no policy or entitlement reason to request the county, and we are removing it for consistency with other recently updated forms.

• Change #5: We are revising the Privacy Act Statement on this form.

Justification #5: 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.