SSA-1026 change sheet justification

OMB Change Sheet

SSA-1026-OCR-SM-SCE, SSA-1026-OCR-SM-REDE and SSA-1026-B

Statement for Continuing Eligibility for Extra Help

with Medicare Prescription Drug Plan Costs

OMB 0960-0723

Collection Background

The Forms SSA-1026-OCR-CM-SCE, SSA-1026-OCR-SM-REDE and SSA-1026-B are used exclusively for redeterminations of eligibility for Medicare Part D Low Income Subsidy (LIS). The forms have 16 questions and are self-help, optical scanner forms. The information is used to determine whether SSI recipients continue to meet all statutory and regulatory requirements for Medicare Part D eligibility and whether they are receiving the correct LIS amount.

Reason for Change

Revised penalty clause removes statement that beneficiary may be sent to prison for a false or misleading statement. This shorter version of the penalty clause is used in numerous other OMB approved SSA forms. This shorter version of the penalty clause was vetted through SSA’s Office of Inspector General in 2002 and in 2007. SSA has received many requests from Senators, U.S. Representatives and advocacy organizations to utilize the shorter version.

Current version reads:

I/We understand that by submitting this information I am/we are declaring under penalty of perjury that I/we have examined all the information on this form and it is true and correct to the best of my/our knowledge. I/We understand that anyone who knowingly gives a false or misleading statement about a material fact in this information, or causes someone else to do so, commits a crime and may be sent

to prison or may face other penalties, or both. I/We understand that the Social Security Administration (SSA) will check my/our statements and compare its records with records from Federal, State, and local government agencies, including the Internal Revenue Service to make sure the determination is correct.

By submitting this information I am/we are authorizing SSA to obtain and disclose information related to my/our income, resources, and assets, foreign and domestic, consistent with applicable privacy laws .This information may include, but is not limited to, information about my/our wages, account balances, investments, insurance policies, benefits, and pensions.

Revisions to the Collection Instrument

Update penalty clause to read:

I/We understand that the Social Security Administration (SSA) will check my/our statements and compare its records with records from Federal, State, and local government agencies, including the Internal Revenue Service (IRS) to make sure the determination is correct. By submitting this application, I am/we are authorizing SSA to obtain and disclose information related to my/our income, resources, and assets, foreign and domestic, consistent with applicable privacy laws. This information may include, but is not limited to, information about my/our wages, account balances, investments, insurance policies, benefits, and pensions. I/We declare under penalty of perjury that I/we have examined all the information on this form and it is true and correct to the best of my/our knowledge.

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