Justification for Nonsubstantive Change Request 0960-0456

Justification for Non-Substantive Changes for Form SSA-8011-F3

Statement of Household Expenses and Contributions

20 CFR 416.1130-1148

OMB No. 0960-0456

Background

The Social Security Administration (SSA) uses form, SSA-8011-F3 to determine whether the Claimant or Recipient receives in-kind support and maintenance. Currently, the paper and PDF versions of this form includes a signature requirement.

SSA recently reassessed the need for the respondent’s signature on this form and determined that we no longer require it. Therefore, we are removing the signature requirement from this form.

Revision to the Information Collection

• Change #1: SSA is removing the signature requirement from Form SSA-8011-F3.

Justification #1: We reassessed the need for a wet signature on this form and determined we no longer require it. Therefore, we will no longer ask respondents to sign this form prior to submitting it to SSA.

• Change #2:  We are replacing the Penalty of Perjury Statement with a Penalty of Perjury Warning: Anyone who knowingly makes or causes to be made a false statement or representation of material fact for use in determining a payment under the Social Security Act, or knowingly conceals or fails to disclose an event with an intent to affect an initial or continued right to payment, or submits or causes to be submitted any false statement or document knowing the same to contain any misrepresentation of material fact, commits a crime punishable under Federal law by fine, imprisonment, or both, and may be subject to administrative sanctions.

Justification #2:  The Penalty of Perjury Statement is directly connected to the signature and needs to be removed since a signature is no longer required. However, to maintain the intent of that statement, it will be replaced with a Penalty of Perjury Warning.

After OMB approves the signature removal for this form, we will implement the new version of the form that clarifies that we no longer require a signature by removing the signature block.

These revisions will not change the current burden for the information collection.