Addendum to the Supporting Statement for 0960-0105

Addendum - 0105.doc

Advanced Notice of Termination of Child's Benefits, and Student's Statement Regarding School Attendance

Addendum to the Supporting Statement for 0960-0105

OMB: 0960-0105

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Addendum for Form SSA-1372-BK and SSA-1372-BK-FC,

Advance Notice of Termination of Child’s Benefits and

Student’s Statement Regarding School Attendance

20 CFR 404.350-404.352, 404.367-404.368

OMB # 0960-0105


Revision to the Collection Instrument

Change: We are adding a perjury statement to page 4 of the SSA-1372-BK and to page 5 of the SSA-1372-BK-FC above the signature field for the school official.

Justification: We are making this addition to the form at the request of the Office of the Inspector General’s Office of the General Counsel.

We will begin using the new version of the form immediately after receiving OMB approval. We plan to destroy the stock of the old version so we can use the new version with the additional perjury statement for school officials.


File Typeapplication/msword
File TitleSupporting Statement for Form SSA-1372-BK and SSA-1372-BK-FC,
AuthorLinda Mitchell, OISP, 51327
Last Modified ByNaomi
File Modified2011-01-21
File Created2011-01-21

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