Addendum to the Supporting Statement for 0960-0014

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

Request to be Selected as Payee

20 CFR 404.2010-404.2055, 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 revisions to the Social Security Protection Act of 2004 (SSPA), P.L. 108-203. Section 103 of the SSPA defines individuals who SSA should not choose to serve as representative payee. Section 203 of the SSPA contains a provision that disqualifies probation or parole violators from serving as representative payee.

• SSA is revising the SSA-11-BK and the reporting responsibilities for Title II, VIII, and XVI beneficiaries and representative payees to reflect these changes:

• Page 4 – add (b) to question 17.

• 17.(a)

Do you have any unsatisfied FELONY warrants (or in jurisdictions that do not define crimes as felonies, a crime punishable by death or imprisonment exceeding 1 year) for your arrest? □YES □NO

If YES: Date of Warrant ______________________

State where warrant was issued________

• 17.(b)

Are you violating a condition of probation or parole imposed by Federal or State law? □YES □NO

• Pages 5, 7 and 9 (Reporting Instructions)

• 2/3 of the way down the page—add a bullet under this lead-in:

In addition to these events about the claimant, you must also notify us if:

• YOU are violating a condition of probation or parole under State or Federal law.

• We are also revising the Paperwork Reduction Act 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 The current language, which dates back to the last reprint of the form, is now outdated.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 Statement on agency forms. As a result, SSA is adding a Privacy Act Statement to this form.