Addendum to the Supporting Statement

Addendum to Supporting Statement

Forms SSA-2854 and SSA-2855

20 CFR 416.1103(f)

(OMB No. 0960-0481)

Revision to the Collection Instrument

Currently on Page 1:

Dear _____:

We need some information about money you provided to _____. He/She has authorized us to contact you concerning any funds you may have provided for his/her use. This information will help us decide if this person is eligible to receive Supplemental Security Income and the amount of the payments. Your response is voluntary. However, if you do not respond, we may not be able to determine if he/she is entitled to certain payments

Change: Revision on page 1

Dear _____:

We need some information about money you provided to _____. He/She has authorized us to contact you concerning any funds you may have provided for his/her use. This information will help us decide a Social Security matter. Your response is voluntary. However, if you do not respond, we may not be able to determine if he/she is entitled to certain payments.

Justification: The bolded text indicates the language currently used on the SSA-2854 and the proposed, revised language, which SSA has changed to prevent disclosure of the specific purpose for requesting the information to a third party and as a means to protect the privacy of the claimant

Change: Revision is on page 2. Remove SSN Section

Justification: The SSN section makes available the Social Security number of the claimant to a third party; therefore, this section has been removed by SSA to prevent disclosure of personally identifiable information (PII) to a third party who does not have a right to that information and to prevent misuse of PII. This is no way alters the purpose or method of collection of the data. Individuals who are providing the amount of an informal loan and the terms of repayment complete this form.

The agency will implement the revised collection instrument upon receipt of OMB clearance approval. The agency will obsolete the previous version (11-2000) and destroy existing stock upon receipt of OMB clearance approval.

We are revising the PRA statement to reflect our current boilerplate language.  The current language, which dates back to the last reprint of the form, is now outdated.

SSA’s Office of the 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 the first page of the form.