Addendum to Supporting Statement

Addendum to Supporting Statement for Form SSA-8001-BK

Application for Supplemental Security Income

20 CFR 416.305-416.335, Subpart C

OMB No. 0960-0444

Revision to the Collection Instrument

Change 1: We revised the “form title” block.

Justification 1: We revised this section to add the acronym for Supplemental Security Income (SSI) at the end of the title. We also added “(Deferred or Abbreviated)” to make the person completing this form aware that this form is for the deferred or abbreviated version of the application for SSI.

Change 2: We are revising the wording in the “FS-SSA/APP and FS-Referred” blocks

• Old language:

FS-SSA/APP and FS-Referred

• New Language:

SNAP-SSA/APP and SNAP-Referred

Justification 2: The USDA has changed the name of the food stamp program to Supplemental Nutrition Assistance Program (SNAP). We changed the “FS” to “SNAP” in these blocks. The blocks mean that either we completed a SNAP application the same time as the SSA application or we referred the claimants to the SNAP office for them to complete the SNAP.

Change 3: We are adding language to the Preferred Language block

• New Language:

Written: and Spoken:

Justification 3: Since the Modernized Supplemental Security Income Claims System (MSSICS) mandates the technician to annotate both the written and spoken language, we also wanted the paper SSA-8001-BK to ask it to prevent a re-contact with the claimant.

Change 4: We added a question to number 5

• New Language:

A re you and your spouse living together? Yes No

I f no, date you began living apart

Justification 4: We added this question because couple computation rules apply to a man and woman for a month if, as of the first moment of that month each is eligible for benefits, they are married (legally or holding out) to each other, and they live in the same household. There is a question in MSSICS about whether or not the couple has lived together as of any time since the date of the application. Without this information on the SSA-8001, the CR needs to re-contact the claimant for this information.

Change 5: We moved the mailing address to question 19 to ask the claimants mailing.

Justification 5: We moved the mailing address question, so the questions on the paper application would be in the same order as the questions in the MSSICS screen path.

Change 6: We moved the special notice options (SNO) from question 37 to question 20, and revised the SNO language.

• Old Language:

I f you are blind or visually impaired, check the type of mail you want to receive from us:

C ertified Regular Regular with a follow-up phone call

• New Language:

I f you are blind or visually impaired, check the type of mail you want to receive from us:

Standard notice First-Class Standard notice First-Class with a follow-up phone call Standard notice & data CD by First-Class Standard notice Certified Standard & Braille notices by First-Class Standard & large print notices Standard notice & audio CD

Justification 6: We moved the SNO question to follow the new location of the mailing address. Paper applications have the SNO question after the mailing address. We also revised the language in the SNO question to list all of the options that SSA offers as mentioned in GN 04440.030.

Change 7: Part II Living Arrangement, previous question 36. We moved the claimant’s residence address question to the first item asked in this section.

Justification 7: We moved the mailing address question to item 23 so questions on the paper application would be in the same order as the questions in the MSSICS screen path.

Change 8: Previous question 21 (now in location 24 with this revision)—

• Old Language:

Noninstitution (rest home, retirement home or group home)

• New Language:

Noninstitution (rest home, retirement home, foster home or group home)

Justification 8: We added this additional type because in the living arrangements POMS (SI 00835.790) we refer to foster care as a type of non-institutional care.

Change 9: Part IV—INCOME—we revised the language in the section description.

• Old Language:

(List all income received since the first moment of the filing date month or expected in the next 3 months.)

• New Language:

(List all income received since the first moment of the filing date month or expected in the next 3 months.) Include you, your spouse/parents

Justification 9: We added “Include you, your spouse/parents” so the claimant will know that they should include the income of all of these people in this section.

Change 10: Previous question 27, now in location number 30. We revised this question to add a blank line at the bottom of the table. We also moved part of the language for this question to the blank line.

Justification 10: This question asks the claimant to note if anyone pays any bills for him or her directly or gives him or her money to pay bills. The current version of the form does not have a place for the claimant to give this information.

Change 11: Part V and question previously numbered 29, now in location number 32—we revised the wording in the questions to remove all references to “food stamps” and changed them to “SNAP”. We also changed the number to go to if no is marked in part b of question 32.

Justification 11: The USDA has changed the name of the food stamp program to SNAP.

Change 12: We revised the description in section in Part VII – Remarks—

• Old Language:

Use this space for any explanations

• New Language:

(You may use this space for any explanations. Enter the item number before each explanation. If you need more space, use a signed form SSA-795.)

Justification 12: We added this additional text in this section to coincide with the text in the remarks section of the SSA-8000-BK—Applications for Supplemental Security Income (full application).

Change 13: Question 33 (Telephone number)—we removed the telephone number block from this question.

Justification 13: We moved the telephone number block with the mailing address question to item 19. We moved the item so the questions on the paper application will be in the same order as the questions in the MSSICS screen path.

Change 14: Paperwork Reduction Act Statement, page 10--We updated this section.

Justification 14: We updated the statement to bold the font in title and match the statement on the supporting statement template.

We will start using the new version after OMB approval, and will destroy stocks of the old version.