Addendum to Supporting Statement

Addendum to the Supporting Statement

for Form SSA-5-F6

Application for Mother’s or Father’s Insurance Benefits

20 CFR 404.339-404.342, 20 CFR 404.601-404.603

OMB No. 0960-0003

Terms of Clearance:

TERMS OF CLEARANCE: OMB approves this burden reduction due to SSA’s implementation of the Signature Proxy initiative.

SSA has continued to utilize the Signature Proxy initiative, as can be seen through the chart in #12 of the Supporting Statement and the IC in ROCIS. Since this initiative has been successful, we intend to continue it indefinitely.

Explanation of Changes:

We will insert the following statement on the Form SSA-5 as indicated on the mock-up:

“For additional information about this application a factsheet to Form SSA-5 is available at www.socialsecurity.gov.”

Question 5

Has an unmarried child or dependent grandchild of the Deceased, who is under age 16 or disabled, lived with you any time from the month of death through the present month? (Include natural child, adopted child, stepchild, and step grandchild.)

We removed the word “natural” to be more accurate. This term is not defined in the Social Security Act and no longer accurately describes all children who qualify for benefits under State law pursuant to Section 216(h)(2) of the Act. In addition, the word “This” was inserted in the last sentence. The last sentence now reads (This includes adopted child, stepchild, and step grandchild.)

Questions 11 and 12

SSA has streamlined the marriage documentation policy for Title II claims to only ask for those marriages that could create entitlement or cause a material discrepancy. The applicant will no longer list all marriages.

The following are the revised Questions 11 and 12:

Revisions for Questions 11 and 12

11. INFORMATION ABOUT YOUR MARRIAGE(S)

1. Enter information about your marriage to the deceased.

Spouse’s Name (including maiden name)	When (Month, day, year)	Where (Name of City and State)
How Marriage Ended	When (Month, day, year)	Where (Name of City and State)
Marriage performed by: ___ Clergy or public official ___ Other (Explain in “Remarks”)	Spouse’s date of birth (or age)	Date of death

2. I

   
   

   f you remarried after the marriage shown in 11. (a), enter information about the last marriage. If none, check here.

Spouse’s Name (including maiden name)	When (Month, day, year)	Where (Name of City and State)
How Marriage Ended	When (Month, day, year)	Where (Name of City and State)
Marriage performed by: ___ Clergy or public official ___ Other (Explain in “Remarks”)	Spouse’s date of birth (or age)	If spouse deceased, give date of death
Spouse’s Social Security Number (If “None” or “Unknown”, so indicate)

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c) If you had other marriages, and the marriage lasted at least 10 years or ended due to death of the spouse (whether before or after you married the deceased), enter the information below. If you divorced then remarried the same individual within the year immediately following the year of the divorce, and the combined period of marriage totaled 10 years or more, include the marriage. If none, check here.

Spouse’s Name (including maiden name)	When (Month, day, year)	Where (Name of City and State)
How Marriage Ended	When (Month, day, year)	Where (Name of City and State)
Marriage performed by: ___ Clergy or public official ___ Other (Explain in “Remarks”)	Spouse’s date of birth (or age)	If spouse deceased, give date of death
Spouse’s Social Security Number (If “None” or “Unknown”, so indicate)

(Use “Remarks” space on back of page for information about any other previous marriage.)

12. INFORMATION ABOUT THE DECEASED’S MARRIAGE (S)

Answer this item ONLY if the deceased had other marriages.

(

a) If the deceased married after his or her marriage to you, enter the information on the last marriage. If none, check here.

.

Spouse’s Name (including maiden name)	When (Month, day, year)	Where (Name of City and State)
How Marriage Ended	When (Month, day, year)	Where (Name of City and State)
Marriage performed by: ___ Clergy or public official ___ Other (Explain in “Remarks”)	Spouse’s date of birth (or age)	If spouse deceased, give date of death
Spouse’s Social Security Number (If “None” or “Unknown”, so indicate)

(

b) Enter information about any other marriage the deceased may have had that lasted at least 10 years (see item 11. (c) for counting consecutive multiple marriages to the same individual) or ended due to death of the spouse (whether before or after you married the deceased). Do not include the marriage to you. If none, check here.

Spouse’s Name (including maiden name)	When (Month, day, year)	Where (Name of City and State)
How Marriage Ended	When (Month, day, year)	Where (Name of City and State)
Marriage performed by: ___ Clergy or public official ___ Other (Explain in “Remarks”)	Spouse’s date of birth (or age)	If spouse deceased, give date of death
Spouse’s Social Security Number (If “None” or “Unknown”, so indicate)

(Use “Remarks” space on back of page for information about any other previous marriage.)

Questions 19 and 20

19. Do you have any unsatisfied felony warrants for your arrest?

20. Do you have any unsatisfied Federal or State warrants for your arrest for violating the conditions of your probation or parole?

We removed these questions based on a directive from the SSA Commissioner as part of the Ready Retirement initiative to streamline the application. The agency will no longer ask the Title II applicant questions regarding unsatisfied felony or probation or parole warrants on any Title II application.

Minor Editorial Changes:

SSA made editorial changes to show the word “deceased” in lower case throughout the document.

Other minor editorial changes SSA made to the title and language for the Privacy Act Notice and Paperwork Reduction Act Statements to make them consistent with already approved wording.

SSA changed the wording in the 3^rd bullet under “How to Report” to include the words “at the phone number and address shown”.

SSA made minor editorial changes to the format, title, and language for the Privacy Act Notice and Paperwork Reduction Act Statements.

SSA-5 INST – Minor Editorial Changes

Above the heading “How to Report,” insert new heading “Work and Earnings.” Move the paragraph at the bottom of the page that begins “For those under full retirement age,...” to under the new heading “Work and Earnings.” This change makes the instructions easier to read and follow.

Under the heading “How to Report,” in the third bullet, insert “at the phone number and address shown.” in place of “shown on your claim receipt.

SSA changed bullet 7 to correct a typographical error.

SSA made minor editorial changes to the format, title, and language for the Privacy Act Notice and Paperwork Reduction Act Statements.

We will obsolete and destroy existing stock of the SSA-5.

On the SSA webpage factsheet to Form SSA-5, we will insert the following statement after where it reads “The dates of each of your marriages and, for marriages that have ended, how and when they ended.” add “We ask marital information to determine eligibility for various benefits (i.e., spouse’s, widow(er)’s, etc.).” (See supplementary documents for mock-up.)