Addendum to the Supporting Statement for 0960-0010

Addendum to the Supporting Statement for Form SSA-4-BK

Application for Child’s Insurance Benefits

20 CFR 404-350 – 404.368 and 404.603, CFR 414.350

OMB No. 0960-0010

Revisions to the Collection Instrument:

• We are updating the Paperwork Reduction Act Statement;

• We are updating the MCS screens to more closely reflect the currently approved version of the Form SSA-4-BK. These revisions have already been approved by OMB in previous clearance packages.

Revisions to the MCS screens:

• On the CHD1 screen, we are adding the SSI question “*Select filed or intend to file for SSI” to clarify the intent. Also, this is already asked on the current, OMB approved, paper version. (#19 on the paper version.)

• The CHD2, which collects information regarding whether or not the child was living with the Number Holder or if the child was adopted, screen is new. The information collected on that screen is OMB approved and currently collected on the paper SSA-4-BK. The addition of this screen mirrors the paper version more closely. (#3 and #16 on the paper version.)

• On the NHID screen we have reworded the language to clarify the categories of children. This was done to mirror the paper version. (#3 of the paper version lists the categories of children.)

• The CHPE screen, which collects information regarding potential entitlement on an adoptive, step or other parent record as well as potential entitlement on a grand or step grandparent record, is new. The information collected on that screen is OMB approved and currently collected on the paper SSA-4-BK. The addition of this screen makes the MCS screens mirror the paper application. (#3 on the paper version establishes the reference to the categories of children; #10 establishes whether or not anyone else has ever filed for the child(ren) before; #16 establishes if the child(ren) have lived with the Worker, which helps determine eligibility under the (step/adoptive) parent’s or grandparent’s record.)

• On the IDEN screen we have reworded the language to clarify the categories of children. This was done to mirror the paper version. (#3 of the paper version lists the categories of children.)

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