Addendum to Supporting Statement

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Addendum to the Supporting Statement for Form SSA-11-BK

Request to be Selected as Payee

20 CFR 404.2010-404.2025, 20 CFR 416.601-416.665

OMB No. 0960-0014

Revisions to the Collection Instrument:

The following are the revisions to the SSA-11-BK as a result of the “Black Lung Consolidation of Administrative Responsibilities Act” (P.L. 107-275) which transferred the administration of the Black Lung Program to the Department of Labor. SSA has revised the questions on the SSA‑11-BK and the reporting responsibilities for representative payees receiving title II, VIII, and XVI benefits on behalf of the beneficiary. In addition, SSA is making minor changes for clarification and streamlining purposes.

• Page 1:

• Between Question 1 and 2 – SSA is changing the existing statement to read:

I request that the social security, supplemental security income or special veterans benefits for the claimant(s) named above be paid to me as representative payee.

• Question 5 – SSA is changing this question to read:

Does the claimant have a court-appointed legal guardian/conservator? Yes No

IF YES, enter the legal guardian’s/conservator’s:

NAME___________________________________________

ADDRESS________________________________________

PHONE NUMBER _________________________________

TITLE ____________________________________________

DATE OF APPOINTMENT ___________________________

• Page 3:

• Question 10 was previously question 14 on the old version. SSA is moving it above the statement “Information About Institutions, Agencies and Banks Applying To Be Representative Payee.” SSA is revising it to read:

Does the claimant owe you/your organization any money now or will he/she owe you/your organization money in the future? Yes No

If YES, enter the amount he/she owes you/your organization, the dates, the debt was/will be incurred and describe why the debt was/will be incurred.

• Question 11- We are deleting the current #11 and making #10 from the old version of the form into the new #11. The information captured in the old #11 question will now be captured in the new Question #10 above.

• Question 14- This was previously question 15 in the old version of the form.

• Question 15 – This was previously question 16 on the old version of the form and has been revised to remove “or Black Lung” from the third checked box.

• Question 16- This was previously question 17 in the old version of the form.

• Page 4:

• Question 17- This was previously question 18 in the old version of the form.

• Question 18- This was previously question 19 in the old version of the form. It has been revised to delete the second line “(If less than 1 year, enter previous address in Remarks).”

• We are capitalizing the word “ZIP” in ZIP Code at the bottom of the page.

• Pages 9 and 10

• Reporting Responsibilities for Black Lung – Has been deleted

• SSA is renumbering the pages that were previously pages 11 and 12 in the old version of the form.

• In addition, SSA is also revising all of the PRA Statements for this form. Since we estimate 10.5 minutes to read the instructions, gather the facts and answer the questions regardless of which type of applicant, we are only attaching one revised PRA Statement to the mock-up of the form.

• Further, SSA’s Office of 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 this form.

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