Revision Addendum SSA-8202-BK

Revision Addendum

SSA-8202-BK Statement for Determining Continuing

Eligibility Supplemental Security Income Payment

OMB 0960-0145

Collection Background

The Form SSA-8202-BK is used exclusively for low probably of error profile (LEP) redeterminations. It is mailed on a 6-year cycle to recipients who complete it with a personal contact interview with an Agency employee. The form has 17 questions. The information is used to determine whether SSI recipients' have met and continue to meet all statutory and regulatory requirements for SSI eligibility and whether they have been and are still receiving the correct payment amount.

Reason for Change

SSA is seeking three changes to the SSA-8202-BK:

1. Question 7. Temporary Assistance to Needy Families (TANF) is listed twice – once under the list of income to count and then listed as a “Do Not Count” item. The TANF listed under “Do Not Count” is an error and will be removed. We are also changing the heading, “Do Not Count” to read, “Do Not List.” We feel this change is easier for the public to understand.

2. The fugitive felon wording on question 16 is obsolete and is being changed to OMB approved language (based on DOJ guidance). The approved language will appear on the revised SSA-8002. The new, revised language will be questions 16 and 17 on the SSA-8202-BK:

The new question 16 is:

Do you have any unsatisfied felony warrants for your arrest (Y/N)

In which state or country was the warrant issued?

Was the warrant satisfied (Y/N)

Date warrant satisfied

The new question 17 is:

Do you have any unsatisfied Federal or State warrants for violating the conditions of probation or parole? (Y/N)

In which state or country was the warrant issued?

Was the warrant satisfied? (Y/N)

Date warrant satisfied

The fugitive felon questions on the SSA-8203-BK (OMB No. 0960-0146) are also obsolete and SSA will be seeking changes to this form to include the updated, approved language.

3. In 2005, OMB approved language to incorporate section 213 of the Foster Care Independence Act of 1999. The question below will be added to the SSA-8202-BK as question number 9.

Do you give us permission to obtain any of your financial records from any financial institution? You – Y/N Your Spouse – Y/N

Additionally, Section 213 of the Foster Care Independence Act of 1999 (P.L. 106-169) requires that SSA explain how we will use the permission and how long the permission lasts. Recognizing this, we are adding the below statement underneath the Privacy Act Statement of the SSA-8202-BK. This statement will be located after the Computer Matching Statement:

Access to Financial Information-We have asked you for permission to obtain, from any financial institution, any financial record about you that is held by the institution. We will ask financial institutions for this information whenever we think it is needed to decide if you are eligible or if you continue to be eligible for SSI benefits. Once authorized, our permission to contact financial institutions remains in effect until one of the following occurs: (1) you notify us in writing that you are canceling your permission, (2) your application for SSI is denied in a final decision, or (3) your eligibility for SSI terminates. If you do not give or cancel your permission you will not be eligible for SSI and we will deny your claim or stop your payments.

Attached is a mock-up of the proposed changes.

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