Addendum to Supporting Statement for 0960-0618

Addendum - 0618 - 11-27-13.docx

Social Security Benefits Application

Addendum to Supporting Statement for 0960-0618

OMB: 0960-0618

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0960-0618 can be found here:

Document [docx]

Download: docx | pdf

Addendum to the Supporting Statement for Social Security Benefits Application:

Form SSA-1: Application for Retirement Insurance Benefits

Form SSA-2: Application for Wife’s or Husband’s Insurance Benefits

Form SSA-16: Application for Disability Insurance Benefits

Internet Claim (iClaim) Application Screens

Internet Appointment (iAppointment) Application Screens

20 CFR 404.310-404.311, 404.315-404.322, 404.330-404.333, 404.601-404.603, and 404.1501-404.1512

OMB No. 0960-0618

Revisions to the Collection Instruments:

Changes to iClaim:

The following summarizes the enhanced changes to the iClaim functionality. The attached iClaim screen shots file reflects these changes.

While there are more screens in the actual iClaim application path, we ask the same questions as the Modernized Claims System (MCS) and paper versions. We made changes to related screens to accommodate the new functionality, and clarified some existing screens. The new screens and changes include:

Created a simpler view that provides a more logical step-by-step description of the online process for the “Welcome Page” and “Contact Information.”
Enhanced screens to provide us the opportunity to add functionality and make collecting data more dynamic while customizing questions toward the claimant.
Reorganized questions to differentiate the benefit type and benefit requirements.
Deleted questions that no longer align with our current policy.
Enhanced features within the screens to display definitions and information boxes.
Added new language and buttons to provide clearer instructions.

Below is a summary of changes and additions for the revised iClaim screens:

Welcome page – Applicants receive this screen after selecting the type of benefits for which they are applying. The current screen displays vast information and option buttons to start the online process, making it difficult to follow a specific order. We modified the screen to simplify the view and to provide a more logical step-by-step description of the online process. This change applies to our welcome pages for retirement insurance benefits (RIB), disability insurance benefits (DIB), and Medicare. We also modified the language to fit the needs of the i3368 form on the DIB welcome page. (Modified Screen #1)

Who Is Completing This Application – We currently display this information as part of the “Welcome” screen; however, to simplify the welcome screen, we moved this portion of the page to its own screen. The new screen provided us with the opportunity to add functionality to the question and make it more dynamic. For the first option, if the applicant is a first party (i.e., selects the 1^st or 2^nd option) then the screen displays the “blind or visual impaired” question. If the applicant is a 3^rd party, the screen displays no additional question. (Modified Screen #2)

Information About You – We currently ask the disability question after the claimant submits all the personal information and establishes protective filing. We moved this question to the initial page of iClaim to determine (up front) if the claimant meets the disability requirements, and to differentiate individuals filing for other benefits as well RIB/DIB. We also added a message indicating claimants should contact their local field office if they answer “yes” to “Have you been diagnosed with any specific condition that is expected to end in death?” (Modified Screen #3)

Contact Information Page:

We currently provide a “bar” at the top of the screens to identify the iClaim sections and the respective questions. We added an additional bar to the top of all the disability screens to indicate the four steps involved with the online disability process. (Modified Screen #4)

Ability to communicate in English – Currently there are no questions about the ability to communicate in English on this screen. We added these questions to facilitate the information propagation into the i3368 form and make the transition less confusing. (Modified Screen#5)

Language preferences – We currently display a drop down for the claimant to select the language preference. We added a note under the language preference to clarify the information is used for communication purposes. (Modified Screen#5)

Re-Entry Number:

Application definition removed – We currently present this page as the “Application Number” screen. We changed the current term “Application Number” to “Re-entry Number” since the user will use this number to return either to the iClaim application or to the i3368 medical form. (Modified Screen #6)

SSI Definition Display – We currently offer a link to “click” for more information about the SSI program. We changed the link to a “hovering informational display.” Applicants will be able to hover over the underlined language and have the SSI information automatically displayed rather than clicking and being taken to another page. (Modified Screen #6)

Return to Saved Application Process – We currently display this information to “restart” your benefit application. We changed the current terms:

“Benefit application” to “Apply for benefits”
“Application Number” to “Re-entry Number”

We made these changes because we will display this screen to all applicants who are returning either to the iClaim application or to the i3368. (Modified Screen #7)

Children – We currently have the same language and information shown in this screen; however, we do not have a leading question to determine if the applicant has children. Therefore, we automaticaly ask for the children information. We added a new functionality within the leading question to avoid asking the subsequent information if unnecessary. If the applicant answers “no” to the first question, we will display no additional questions. If the applicant anwers “yes” then we will display conditional questions. We are making this change to make the question more dynamic. (Modified Screen #8)

Supplemental Information – We currently ask for information about corporate work. We removed the Corporate Officer questions because of a recent policy change. (Modified Screen #9)

Ability to Work – We currently ask for “the Disability Conditions” a claimant has (e.g. broken leg, depression, etc.); however, the “description of the condition” is not needed as part of the application because the i3368 asks the same information. We removed this question from this page and the paper application to eliminate duplicate data entry. (Modified Screen #10)

Authorization – We currently present a “yes” or “no” option for the following statement “I authorize disclosure of medical information”; however, the SSA-827 collects the same information. We removed this question from this page and the paper application to eliminate duplicate data entry. (Modified Screen #11)

Review and Sign – We currently display this as “review and submit” at the top of the screen (next to remarks). We changed the term to “review and sign.” We made this change to make a smooth transition to the next page which is the starting point of the i3368. (Modified Screen #12)

Electronic Signature – The current language in this page refers to the disability application only. We updated the language on this page to reflect the connection of the iClaim and the i3368 applications. We also changed the button at the bottom of the page “Accept and Continue to Step 2” so applicants realize they are done with this portion of the application, but additional steps remain. (Modified Screen #13)

Spanish iClaim only:

Transition from Spanish iClaim to i3368 (available in English only) – We currently provide the Spanish iClaim applicant with a confirmation number and a message stating the next steps to complete the disability process (e.g., i3368). We also inform the applicant that the rest of the disability process is only available in English. We modified this page by separating the confirmation number from the “what’s next” instructions to improve readability and clarity, so that it is less confusing to the applicant. The new screen provides instructions and radio buttons to indicate what the applicants would like to do next. Depending on the selected option, the claimant will receive either 1) a confirmation number screen, or 2) the i3368 questions to continue with the process. This is a new screen displayed in Spanish; we provided the translation in English for your convenience. (Modified Screen #14)

Revisions to the SSA-1-BK

Change 1: Page 1 – deleted question number 3

Justification 1: Effective September 29, 2012, we terminated the automated generation of Password Request Code (PRC) notices when an individual files for benefits online or answers “yes” to the question about getting a password in MCS. In addition, we removed this functionality from the MCS application.

Change 2: Pages 1 through 5 – Renumbered all questions, including directions that point to specific questions.

Justification 2: We renumbered these items following the deletion of question 3.

Change 3: Page 1 – renumbered question 4(b)—revised the language

From:

Enter name of State or foreign country where you were born.

To:

Enter name of city and state, or foreign country where you were born.

Justification 3: We revised the language to add “city”, make “state” lowercase, and add a comma after “state” to make this question consistent with the same questions on the other forms in this package and to make the sentence grammatically correct.

Change 4: Page 2, renumbered question 11(c)—we revised the language in this question

From:

Have you ever been (or will you be) eligible for monthly benefits from a military or civilian Federal agency? (including Veterans Administration benefits only if you waived Military retirement pay).

To:

Have you ever been (or will you be) eligible for monthly benefits from a military or civilian Federal agency? (Include Veterans Administration benefits only if you waived Military retirement pay).

Justification 4: We revised this language because it is grammatically incorrect in the current version.
Change 5: Page 2, renumbered question 14(a) and the paragraph between renumbered questions 14 and 15 – reworded the language

From:

(question) Are you entitled to, or do you expect to be entitled to, a pension or annuity based on your work after 1956 not covered by Social Security?

(paragraph) I agree to promptly notify the Social Security Administration if I become entitled to a pension or annuity based on my employment not covered by Social Security, or if such pension or annuity stops.

To:

(question) Are you entitled to, or do you expect to be entitled to, a pension or annuity (or a lump sum in place of a pension or annuity) based on your work after 1956 not covered by Social Security?

(paragraph) I agree to promptly notify the Social Security Administration if I become entitled to a pension, an annuity, or a lump sum payment based on my employment not covered by Social Security, or if such pension or annuity stops.

Justification 5: We reworded the language to include information about lump sum payments.

Change 6: Page 3, question 16(a), first sentence in the question—redirected the applicant to go to 16(b) instead of 17.

Justification 6: We revised this language to correct an error in the directional numbers.

Change 7: Page 3, question 16(b), the paragraph under the bulleted items—revised the language

From:

Use the “Remarks” space to enter the additional marriage information. If none, write “None”____________ Go on to item 16(c) if you have a child(ren) who is under age 16 or disable or handicapped (age 16 or over and disability begain before age 22)…

To:

Use the “Remarks” space to enter the additional marriage information. If none, write “None”____________ Go on to item 16(c) if you have a child(ren) who is under age 16 or disabled or handicapped (age 16 or over and disability began before age 22)…

Justification 7: We revised this language to add a “d” to the word “disable” and correct the spelling of the word “began.”

Change 8: Page 3, question 16(c), first bullet—revised the language

From:

Have a child(ren) who is under age 16 or disable or handicapped (age 16 or over and disability begain before age 22)…

To:

Have a child(ren) who is under age 16 or disabled or handicapped (age 16 or over and disability began before age 22)…

Justification 8: We revised this language to add a “d” to the word “disable” and correct the spelling of the word “began.”

Change 9: Page 3, bolded statement at the bottom—revised the language

From:

If your claim for retirement benefits is approved, your children (including adopted children, and stepchildren) or dependent grandchildren (including step & grandchildren) may be eligible for benefits based on your earnings record.

To:

If your claim for retirement benefits is approved, your children (including adopted children and stepchildren) or dependent grandchildren (including step grandchildren) may be eligible for benefits based on your earnings record.

Justification 9: We revised this language to remove the comma in the first parenthetical statement and to remove the ampersand between “step” and “grandchildren.”

Change 10: Page 4, renumbered question 17, parenthetical in first sentence—revised the language

From:

(including natural children, adopted children and stepchildren)

To:

(including adopted children and stepchildren)

Justification 10: We revised the language to remove “natural children” because this term is not defined in the Social Security Act (Act) and no longer accurately describes all children who qualify for benefits under State law pursuant to Section 216(h)(2) of the Act.

Change 11: Page 4, renumbered question 17, sentence after the bulleted items—revised the language

From:

Also list any student who is between the ages of 18 to 23 if such student was both: 1. Previously entitled to Social Security benefits on any Social Security record for August 1981; and 2. In full-time attendance at a post-secondary.

To:

Justification 11: We revised this language to add the word “school” to the end.

Change 12: Page 4, renumbered question 19—deleted “(a),” and removed part (b).

Justification 12: We removed part (b) of this question because we eliminated the Questionable Retirement (QR) policy that supported this question effective 1/2011.

Change 13: Page 4, renumbered question 22; page 5, renumbered questions 23 and 24 – changed the name of the referenced publication

From:

“How Your Earnings Affect Your Benefits”

To:

“How Work Affects Your Benefits”

Justification 13: We corrected the title of the publication based on current policy.

Change 14: Page 5, Medicare Information—revised the language

From:

If this claim is approved and you are still entitled to benefits at age 65, or you are withing 3 months of age 65 or older you could automatically receive Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage at age 65. If you are not eligible for automatic enrollment in Medicare Part B, and you will need to contact Social Security to request enrollment.

To:

If this claim is approved and you are still entitled to benefits at age 65, or you are within 3 months of age 65 or older you could automatically receive Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage at age 65. If you live in Puerto Rico or a foreign country, you are not eligible for automatic enrollment in Medicare Part B, and you will need to contact Social Security to request enrollment.

Justification 14: We revised this language to correct a typographical error in the word “within” and to add information about people living in Puerto Rico or a foreign country not being eligible for automatic enrollment in Medicare Part B.

Change 15: Page 5, second part “Medicare Information” section—revised the information in this section

From:

Medicare Part B (Medical Insurance)- helps cover a doctor's services and outpatient care. It also covers some other services that Medicare Part A doesn’t cover, such as some of the services of physical and occupational therapists and some home health care. If you enroll in Medicare Part B, you will have to pay a monthly premium. The amount of your premium will be determine when your coverage begins. In some cases, your premium may be higher based on information about your income we receive from the Internal Revenue Service. Your premiums will be deducted from any monthly Social Security, Railroad Retirement, or Office of Personnel Management benefits you receive. If you do not receive any of these benefits, you will get a letter explaining how to pay your premiums. You will also get a letter if there is any change in the amount of your premium.

You can also enroll in a Medicare prescription drug plan (Part D). To learn more about Medicare prescription drug plans and when you can enroll, visit www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048). Medicare can also tell you about agencies in your area that can help you choose your prescription drug coverage.

If you have limited income and resources, we encourage you to apply for the Extra Help that is available to assist you with Medicare prescription drug costs. The Extra Help can pay the monthly premiums, annual deductibles, and prescription co-payments. To learn more or apply, please visit www..socialsecurity.gov, call 1-800-772-1213 (TTY 1-800-325-0778) or visit the nearest Social Security office.

To:

Medicare Part B (Medical Insurance) helps cover doctor's services and outpatient care. It also covers some other services that Medicare Part A does not cover, such as some of the services of physical and occupational therapists and some home health care. If you enroll in Medicare Part B, you will have to pay a monthly premium. The amount of your premium will be determined when your coverage begins. In some cases, your premium may be higher based on information about your income we receive from the Internal Revenue Service. Your premiums will be deducted from any monthly Social Security, Railroad Retirement, or Office of Personnel Management benefits you receive. If you do not receive any of these benefits, you will get a letter explaining how to pay your premiums. You will also get a letter if there is any change in the amount of your premium.

You can also enroll in a Medicare prescription drug plan (Part D). To learn more about the Medicare prescription drug plans and when you can enroll, visit www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048). Medicare can also tell you about agencies in your area that can help you choose your prescription drug coverage. The amount of your premium varies based on the prescription drug plan provider. The amount you pay for Part D coverage may be higher than the listed plan premium, based on information about your income we receive from the Internal Revenue Service.

If you have limited income and resources, we encourage you to apply for the Extra Help that is available to assist you with Medicare prescription drug costs. The Extra Help can pay the monthly premiums, annual deductibles, and prescription co-payments. To learn more or apply, please visit www.socialsecurity.gov, call 1-800-772-1213 (TTY 1-800-325-0778) or visit the nearest Social Security office.

Justification 15: We revised this language to correct typographical errors and to add language about the cost of Medicare Drug Plans.

Change 16: Page 6, declaration statement—we revised the language in the second sentence of this statement

From:

I understand that anyone who knowingly gives false or misleading statement about a material fact in this information, or causes…

To:

I understand that anyone who knowingly gives a false or misleading statement about a material fact in this information, or causes…

Justification 16: We revised this language to add “a” between “gives” and “false.”

Change 17: Page 6 – revised the direct deposit information

From:

FOR

OFFICIAL

USE

ONLY

DIRECT DEPOSIT PAYMENT ADDRESS (FINANCIAL INSTITUTION)

Routing Transit Number

C/S Number

Depositor Account Number

No Account

Direct Deposit

Refused

To:

DIRECT DEPOSIT PAYMENT INFORMATION (FINANCIAL INSTITUTION)

Routing Transit Number

Account Number

Checking

Savings

Enroll in Direct Express

Direct Deposit Refused

Justification 17: We revised this information to add a block to enroll in Direct Express. Because of the Department of Treasury’s mandate to issue benefit payments electronically this question is required in MCS. Revising this question avoids SSA’s need to re-contact the applicant.

Change 18: Page 8, sixth bulleted item in the left column—we changed this statement

From:

You are confined to jail, prison, penal institution or correctional facility for conviction of a crime or confined to a public institution by court order in connection with a crime.

To:

You are confined to a jail, prison, penal institution or correctional facility for more than 30 continuous days for conviction of a crime, or you are confined for more than 30 continuous days to a public institution by a court order in connection with a crime.

Justification 18: This change is necessary for the reporting responsibility to conform to the non-payment requirements of the Social Security Act in section 202(x)(1).

Change 19: Page 8, seventh bulleted item in the left column—we changed this statement

From:

You have an unsatisfied warrant for your arrest for a crime or attempted crime that is a felony (or, in jurisdictions that do not define crime as felonies, a crime that is punishable by death or imprisonment for a term exceeding 1 year).

To:

You have an unsatisfied warrant for more than 30 continuous days for your arrest for a crime or attempted crime that is a felony of flight to avoid prosecution or confinement, escape from custody and flight-escape. In most jurisdictions that do not classify crimes as felonies, this applies to a crime that is punishable by death or imprisonment for a term exceeding one year (regardless of the actual sentence imposed).

Justification 19: We changed this reporting responsibility because of the Martinez Settlement. The Martinez Settlement is a nation-wide class action settlement that caused us to stop our practice of suspending benefits for an outstanding felony warrant unless the courts issued the warrant for a crime or attempted crime of flight to avoid prosecution or confinement, escape from custody and flight-escape.

Change 20: Page 8, eighth bulleted item in the left column—we changed this statement

From:

You have an unsatisfied warrant for a violation of probation or parole under Federal or State law.

To:

You have an unsatisfied warrant for more than 30 continuous days for a violation of probation or parole under Federal or State law.

Justification 20: This change is necessary due to the Clark Court Order (dated 3/19/10) requiring that we no longer suspend benefits based on an outstanding probation or parole violation warrant.

Change 21: Page 8, ninth bulleted item in the left column—changed the statement

From:

You become entitled to a pension or annuity based on your employment not covered by Social Security, or if such pension or annuity stops.

To:

You become entitled to a pension, an annuity, or a lump sum payment based on your employment not covered by Social Security, or if such pension or annuity stops.

Justification 21: We reworded the language to include information about lump sum payments.

Change 22: Page 8, “How to Report” section—changed the language in the first sentence of this section

From:

You can make your reports by telephone, mail, or in person, whichever you prefer.

To:

You can make your reports online, by telephone, mail, or in person, whichever you prefer.

We also changed the language in the first bullet:

From:

Visiting the section “What You Can Do Online” at our web site at www.socialsecurity.gov.

To:

Visiting the section “my Social Security” at our web site at www.socialsecurity.gov.

Justification 22: We made this change because of SSA’s addition of the “my SSA” Internet page.

Change 23: Page 8, “How to Report” section, last bullet—changed the language

From:

Calling, visiting or writing your local Social Security office.

To:

Calling, visiting, or writing your local Social Security office at the phone number and address shown on your claim receipt.

Justification 23: We made this change so the language will be consistent for all forms in the package.

Revisions to SSA-1-INST

Change 1: Page 1, sixth bulleted item in the left column—we changed this statement

From:

You are confined to jail, prison, penal institution or correctional facility for conviction of a crime or confined to a public institution by court order in connection with a crime.

To:

Justification 1: This change is necessary for the reporting responsibility to conform to the non-payment requirements of the Social Security Act in section 202(x)(1).

Change 2: Page 1, seventh bulleted item in the left column—changed the statement

From:

You become entitled to a pension or annuity based on your employment after 1956 not covered by Social Security, or if such pension or annuity stops.

To:

You become entitled to a pension, an annuity, or a lump sum payment based on your employment not covered by Social Security, or if such pension or annuity stops.

Justification 2: We reworded the language to include information about lump sum payments.

Change 3: Page 1, eighth bulleted item in the left column—we changed this statement

From:

To:

Justification 3: We changed this reporting responsibility because of the Martinez Settlement (explained above in Justification 19 for the SSA-1-BK).

Change 4: Page 1, ninth bulleted item in the left column—we changed this statement

From:

You have an unsatisfied warrant for a violation of probation or parole under Federal or State law.

To:

You have an unsatisfied warrant for more than 30 continuous days for a violation of probation or parole under Federal or State law.

Justification 4: This change is necessary due to the Clark Court Order (dated 3/19/10) requiring that we no longer suspend benefits based on an outstanding probation or parole violation warrant.

Change 5: Page 8, “How to Report” section—changed the language in the first sentence of this section

From:

You can make your reports by telephone, mail, or in person, whichever you prefer.

To:

You can make your reports online, by telephone, mail, or in person, whichever you prefer.

We also added the following bullet at the bottom to reflect the online services reporting option:

“Visiting the section “my Social Security” at our web site at www.socialsecurity.gov.”

Justification 5: We added this bullet because of SSA’s addition of “my SSA,” and to let claimants know they can make some changes online.

Change 6: Page 1, Notice About Documents—changed the statement

From:

We recommend that you keep all documents you submitted to us.

To:

We recommend that you keep copies of all documents you submitted to us.

Justification 6: We added “copies of” to the first sentence in this section to instruct claimants to keep copies of their documents when they send us the originals.

Revisions to the SSA-2-BK

Change 1: Page 1, directly under the form title, the paragraph starting with the supplement checkbox—we revised the language

From:

If you have already completed an application entitled “APPLICA- TION FOR RETIREMENT INSURANCE BENEFITS”…

To:

If you have already completed an application entitled “APPLICATION FOR RETIREMENT INSURANCE BENEFITS”…

Justification 1: We revised the language to correct a typographical error in the word “Application.”

Change 2: Page 1 – deleted question number 4.

Justification 2: Effective September 29, 2012, we terminated the automated generation of Password Request Code (PRC) notices when an individual files for benefits online or answers “yes” to the question about getting a password in the MCS. Also, we removed this functionality from the MCS application.

Change 3: Pages 1 through 5 – Renumbered all questions, including directions that point to specific questions.

Justification 3: We renumbered these items following the deletion of question 4.

Change 4: Page 1 – renumbered question 5(b)—revised the language

From:

Enter name of city, State or foreign country where you were born.

To:

Enter name of city and state, or foreign country where you were born.

Justification 4: We revised the language to add “city,” make “state” lowercase, and add a comma after “state” to make this question consistent with the same questions on the other forms in this package and to make the sentence grammatically correct.

Change 5: Page 1, renumbered question 8—we revised the language in the question

From:

(a) Have you used any other Social Security Number(s) If “Yes,” what number(s) did you use?

To:

(a) Have you used any other Social Security number(s)?

(b) Enter Social Security number(s) used.

Justification 5: We revised the language to make the second part of the question into part (b) and to make the question easier to read.

Change 6: Page 2, renumbered question 9(b)—revised the language

From:

If “Yes” enter the date you became unable to work.

To:

If “Yes” when do you believe your condition(s) became severe enough to keep you from working (even if you have never worked)?

Justification 6: We revised the language in this question to make it consistent with the wording for the same question on the SSA-3368 Disability Report—Adult.

Change 7: Page 2, renumbered question 11(c)—revised the language

From:

Have you ever been (or will you be eligible for monthly benefit from a military or civilian Federal agency?) (including Veterans Administration benefits only if you waived Military retirement pay)

To:

Have you ever been (or will you be) eligible for monthly benefits from a military or civilian Federal agency (Include Veterans Administration benefits only if you waived Military retirement pay)?

Justification 7: We reworded the language to correct typographical errors and to include information about lump sum payments.

Change 8: Page 2, statement at the very bottom of the page—revised the language

From:

I agree to promptly notify the Social Security Administration if I become entitled to a pension or annuity based on my employment not covered by Social Security, or if such pension or annuity stops.

To:

I agree to promptly notify the Social Security Administration if I become entitled to a pension, an annuity, or a lump sum payment based on my employment not covered by Social Security, or if my pension or annuity amount changes or stops.

Justification 8: We reworded the language to include information about lump sum payments.

Change 9: Page 3, renumbered question 15(a), second sentence in the instructions—revised the language

From:

If you married the worker more than once, use the ‘Remarks’ space to endter the additional marriage information.

To:

If you married the worker more than once, use the ‘Remarks’ space to enter the additional marriage information.

Justification 9: We revised the language to correct a typographical error in the word “enter.”

Change 10: Page 3, renumbered question 15(c), first two sentences in last bullet—revised the language

From:

Were divorced, 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 Use the “Remarks” space to ender the additional marriage information.

To:

Were divorced, 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. Use the “Remarks” space to enter the additional marriage information.

Justification 10: We revised the language to add a period after “more” and before “Use,” and correct a typographical error in the word “enter.”

Change 11: Page 4, renumbered question 17—deleted “(a),” and removed part (b).

Justification 11: We removed part (b) of this question because we eliminated the Questionable Retirement (QR) policy that supported this question effective 1/2011.

Change 12: Page 4, renumbered questions 18, 19, and 20 – changed the name of the referenced publication

From:

“How Your Earnings Affect Your Benefits”

To:

“How Work Affects Your Benefits”

Justification 12: We corrected the title of the publication.

Change 13: Page 5, Medicare Information—revised the language

From:

To:

Justification 13: We revised this language to correct a typographical error in the word “within” and to add information about people living in Puerto Rico or a foreign country not being eligible for automatic enrollment in Medicare Part B.

Change 14: Page 5, second part of “Medicare Information” section—revised the information in this section

From:

Medicare Part B (Medical Insurance) helps cover a doctor's services and outpatient care. It also covers some other services that Medicare Part A doesn’t cover, such as some of the services of physical and occupational therapists and some home health care. If you enroll in Medicare Part B, you will have to pay a monthly premium. The amount of your premium will be determine when your coverage begins. In some cases, your premium may be higher based on information about your income we receive from the Internal Revenue Service. Your premiums will be deducted from any monthly Social Security, Railroad Retirement, or Office of Personnel Management benefits you receive. If you do not receive any of these benefits, you will get a letter explaining how to pay your premiums. You will also get a letter if there is any change in the amount of your premium.

To:

If you have limited income and resources, we encourage you to apply for the Extra Help that is available to assist you with Medicare prescription drug costs. The Extra Help can pay the monthly premiums, annual deductibles, and prescription co-payments. To learn more or apply, please visit www.socialsecurity.gov, call 1-800-772-1213 (TTY 1-800-325-0778) or visit the nearest Social Security office.

Justification 14: We revised this language to correct typographical errors and to add language about the cost of Medicare Drug Plans.

Change 15: Page 6, penalty clause above signature line—revised the language in the second sentence

From:

I understand that anyone who knowingly gives false or misleading statement about material fact in this information…

To:

I understand that anyone who knowingly gives a false or misleading statement about a material fact in this information…

Justification 15: We revised this language to add “a” between “gives” and “false” to correct a typographical error.

Change 16: Page 6 – revised the direct deposit information

From:

FOR

OFFICIAL

USE

ONLY

DIRECT DEPOSIT PAYMENT ADDRESS (FINANCIAL INSTITUTION)

Routing Transit Number

C/S Number

Depositor Account Number

No Account

Direct Deposit

Refused

To:

DIRECT DEPOSIT PAYMENT INFORMATION (FINANCIAL INSTITUTION)

Routing Transit Number

Account Number

Checking

Savings

Enroll in Direct Express

Direct Deposit Refused

Justification 16: We revised this information to add a block to enroll in Direct Express. Because of the Department of Treasury’s mandate to issue benefit payments electronically this question is required in MCS. Revising this question avoids SSA’s need to re-contact the applicant.

Change 17: Page 8, seventh bulleted item in the left column—we changed this statement

From:

You are confined to jail, prison, penal institution or correctional facility for conviction of a crime or confined to a public institution by court order in connection with a crime.

To:

Justification 17: This change is necessary for the reporting responsibility to conform to the non-payment requirements of the Social Security Act in section 202(x)(1).

Change 18: Page 8, eighth bulleted item in the left column—we changed this statement

From:

To:

Justification 18: We changed this reporting responsibility because of the Martinez Settlement (explained above in Justification 19 for the SSA-1-BK).

Change 19: Page 8, ninth bulleted items in the left column—we changed this statement

From:

You have an unsatisfied warrant for a violation of probation or parole under Federal or State law.

To:

You have an unsatisfied warrant for more than 30 continuous days for a violation of probation or parole under Federal or State law.

Justification 19: This change is necessary due to the Clark Court Order (dated 3/19/10) requiring that we no longer suspend benefits based on an outstanding probation or parole violation warrant.

Change 20: Page 8, tenth bulleted items in the left column—changed the statement

From:

You become entitled to a pension or annuity based on your employment not covered by Social Security, or if such pension or annuity stops.

To:

You become entitled to a pension, an annuity, or a lump sum payment based on your employment not covered by Social Security, or if such pension or annuity stops.

Justification 20: We reworded the language to include information about lump sum payments.

Change 21: Page 8, section entitled “Changes To Be Reported And How to Report them”—we added a bullet to read:

Your stepchild is entitled to benefits on your record and you and the stepchild’s parent divorce. Stepchild benefits are not payable beginning with the month after the month the divorce becomes final.

Justification 21: We added this bullet because this item is located on the other applications in this package and is a required reporting responsibility.

Change 22: Page 8, “How to Report” section—changed the language in the first sentence of this section

From:

You can make your reports by telephone, mail, or in person, whichever you prefer.

To:

You can make your reports online, by telephone, mail, or in person, whichever you prefer.

We also changed the language in the first bullet from:

Visiting the section “What You Can Do Online” at our web site at www.socialsecurity.gov.

To:

Visiting the section “my Social Security” at our web site at www.socialsecurity.gov.

Justification 22: We made these changes because of SSA’s addition of “my SSA.”

Revisions to SSA-2-INST

Change 1: Page 1, ninth bulleted item in the left column—we changed this statement

From:

You are confined to jail, prison, penal institution or correctional facility for conviction of a crime or confined to a public institution by court order in connection with a crime.

To:

Justification 1: This change is necessary for the reporting responsibility to conform to the non-payment requirements of the Social Security Act in section 202(x)(1).

Change 2: Page 1, first bulleted item in the right column—we changed this statement

From:

To:

Justification 2: We changed this reporting responsibility because of the Martinez Settlement (explained above in Justification 20 for the SSA-1-BK).

Change 3: Page 1, second bulleted item in the right column—we changed this statement

From:

You have an unsatisfied warrant for a violation of probation or parole under Federal or State law.

To:

You have an unsatisfied warrant for more than 30 continuous days for a violation of probation or parole under Federal or State law.

Justification 3: This change is necessary due to the Clark Court Order (dated 3/19/10) requiring that we no longer suspend benefits based on an outstanding probation or parole violation warrant.

Change 4: Page 1, third bulleted items in the left column—changed the statement

From:

You begin to receive a government pension or annuity (from the Federal government or any State or any political subdivision thereof) or your pension or annuity amount changes.

To:

You begin to receive a government pension, or annuity, or you receive a lump sum payment (from the Federal government or any State or any political subdivision thereof) not covered by Social Security, or your pension or annuity amount changes or stops.

Justification 4: We reworded the language to include information about lump sum payments.

Change 5: Page 1, section entitled “Changes To Be Reported And How to Report them”—we added a bullet to read:

Justification 5: We added this bullet because this item is located on the application and is a required reporting responsibility.

Change 6: Page 1, “How to Report” section—changed the language in the first sentence of this section

From:

You can make your reports by telephone, mail, or in person, whichever you prefer.

To:

You can make your reports online, by telephone, mail, or in person, whichever you prefer.

We also added a bullet to reflect the online services reporting option:

“Visiting the section “my Social Security” at our web site at www.socialsecurity.gov.”

Justification 6: We changed the language and added this bullet because of SSA’s addition of “my SSA,” and to let claimants know they can make some changes online.

Change 7: Page 2, Notice About Documents—changed the statement

From:

We recommend that you keep all documents you submitted to us.

To:

We recommend that you keep copies of all documents you submitted to us.

Justification 7: We added “copies of” to the first sentence in this section to instruct claimants to keep copies of their documents when he or she sends us the originals.

Revisions to the Collection Instrument SSA-16-BK

Change 1: Page 1 – deleted question number 4.

Justification 1: Effective September 29, 2012, we terminated the automated generation of Password Request Code (PRC) notices when an individual files for benefits online or answers “yes” to the question about getting a password in MCS. Also, we removed this functionality from the MCS application.

Change 2: Pages 1 through 4 – Renumbered all questions, including directions that point to specific questions.

Justification 2: We renumbered these items following the deletion of question 4.

Change 3: Page 1 – renumbered question 5(b)—revised the language

From:

Enter name of State or foreign country where you were born.

To:

Enter name of city and state, or foreign country where you were born.

Justification 3: We revised the language to add “city,” make “state” lowercase, and add a comma after “state” to make this question consistent with the same questions on the other forms in this package and to make the sentence grammatically correct.

Change 4: Page 1, renumbered question 9—revised the language

From:

Enter the date you became unable to work because of your illness, injuries, or conditions.

To:

When do you believe your condition(s) became severe enough to keep you from working (even if you have never worked)?

Justification 4: We revised the language to match the wording in the same question on the SSA-3368 Disability Report—Adult.

Change 5: Page 2, renumbered question 12—revised the language

From:

Have your or your spouse worked in the railroad industry for 5 years of more?

To:

Did you or your spouse (or prior spouse) work in the railroad industry for 5 years or more?

Justification 5: We revised this question to include information about the prior spouse.

Change 6: Page 2, renumbered question 14(a)—revised the language

From:

Are you entitled to, or do you expect to become entitled to, a pension or annuity based on your work after 1956 not covered by Social Security?

To:

Are you entitled to, or do you expect to be entitled to, a pension or annuity (or a lump sum in place of a pension or annuity) based on your work after 1956 not covered by Social Security?

Justification 6: We reworded the language to include information about lump sum payments.

Change 7: Page 3, renumbered question 18—deleted “(a)”, and removed part (b).
Justification 7: We removed part (b) of this question because we eliminated the Questionable Retirement (QR) policy that supported this question effective 1/2011.

Change 8: Page 4, current question number 23 that asks what the illnesses, injuries, or conditions that limit the ability to work—we deleted this question.

Justification 8: We deleted this question because the SSA-3368 Disability Report—Adult asks the same question.

Change 9: Page 4 – Renumbered all questions, including directions that point to specific questions.

Justification 9: We renumbered these items following the deletion of current question number 23.

Change 10: Page 4, paragraph entitled “Submitting Medical Evidence” between renumbered questions 22 and 23—we deleted this information.

Justification 10: We deleted this question because the SSA-3368 Disability Report—Adult asks the same question.

Change 11: Page 5 – revised the direct deposit information

From:

FOR

OFFICIAL

USE

ONLY

DIRECT DEPOSIT PAYMENT ADDRESS (FINANCIAL INSTITUTION)

Routing Transit Number

C/S Number

Depositor Account Number

No Account

Direct Deposit

Refused

To:

DIRECT DEPOSIT PAYMENT INFORMATION (FINANCIAL INSTITUTION)

Routing Transit Number

Account Number

Checking

Savings

Enroll in Direct Express

Direct Deposit Refused

Justification 11: We revised this information to add a block to enroll in Direct Express. Because of the Department of Treasury’s mandate to issue benefit payments electronically this question is required in the Modernized Claims Systems (MCS). Revising this question removes SSA’s need to re-contact the applicant.

Change 12: Page 7, sixth bulleted item in the left column—we changed this statement

From:

You are confined to jail, prison, penal institution or correctional facility for conviction of a crime or confined to a public institution by court order in connection with a crime.

To:

Justification 12: This change is necessary in order for the reporting responsibility to conform to the non-payment requirements of the Social Security Act in section 202(x)(1).

Change 13: Page 7, seventh bulleted items in the left column—changed the statement

From:

You become entitled to a pension or annuity based on your employment not covered by Social Security, or if such pension or annuity stops.

To:

You become entitled to a pension, an annuity, or a lump sum payment based on your employment not covered by Social Security, or if such pension or annuity stops.

Justification 13: We reworded the language to include information about lump sum payments.

Change 14: Page 7, ninth bulleted item in the left column—we changed this statement

From:

To:

Justification 14: We changed this reporting responsibility because of the Martinez Settlement (explained above in Justification 19 for the SSA-1-BK).

Change 15: Page 7, tenth bulleted items in the left column—we changed this statement

From:

You have an unsatisfied warrant for a violation of probation or parole under Federal or State law.

To:

You have an unsatisfied warrant for more than 30 continuous days for a violation of probation or parole under Federal or State law.

Justification 15: This change is necessary due to the Clark Court Order (dated 3/19/10) requiring that we no longer suspend benefits based on an outstanding probation or parole violation warrant.

Change 16: Page 7, “How to Report” section—changed the language in the first bullet

From:

Visiting the section “What You Can Do Online” at our web site at www.socialsecurity.gov.

To:

Visiting the section “my Social Security” at our web site at www.socialsecurity.gov.

Justification 16: We made this change because of SSA’s addition of “my SSA.”

Change 17: Page 7, “How to Report” section, last bullet—changed the language

From:

Calling, visiting or writing your local Social Security office.

To:

Calling, visiting or writing your local Social Security office at the phone number and address shown on your claim receipt.

Justification 17: We made this change so the language will be consistent for all forms in the package.

Revisions to SSA-16-INST

Change 1: Page 1, fifth bulleted item in the left column—we changed this statement

From:

You are confined to jail, prison, penal institution or correctional facility for conviction of a crime or confined to a public institution by court order in connection with a crime.

To:

Justification 1: This change is necessary in order for the reporting responsibility to conform to the non-payment requirements of the Social Security Act in section 202(x)(1).

Change 2: Page 1, sixth bulleted items in the left column—changed the statement

From:

You become entitled to a pension or annuity based on your employment not covered by Social Security, or if such pension or annuity stops.

To:

You become entitled to a pension, an annuity, or a lump sum payment based on your employment not covered by Social Security, or if such pension or annuity stops.

Justification 2: We reworded the language to include information about lump sum payments.

Change 3: Page 1, first bulleted item in the right column—we changed this statement

From:

You have an unsatisfied warrant for a violation of probation or parole under Federal or State law.

To:

You have an unsatisfied warrant for more than 30 continuous days for a violation of probation or parole under Federal or State law.

Justification 3: This change is necessary due to the Clark Court Order (dated 3/19/10) requiring that we no longer suspend benefits based on an outstanding probation or parole violation warrant.

Change 4: Page 1, section entitled “Changes To Be Reported And How to Report them”—we added a bullet to read:

Justification 4: We added this bullet because of the Martinez Settlement (explained above in Justification 19 for the SSA-1-BK).

Change 5: Page 1, section entitled “Changes To Be Reported And How to Report them”—we added a bullet to read:

Justification 5: We added this bullet because this item is located on the application and is a required reporting responsibility.

Change 6: Page 1, section entitled “Changes To Be Reported And How to Report them”—we added a bullet to read:

You go outside the U.S.A. for 30 consecutive days or longer.

Justification 6: We added this bullet because this item is located on the application and is a required reporting responsibility.

Change 7: Page 1, “How to Report” section—changed the language in the first bullet

From:

Visiting the section “What You Can Do Online” at our web site at www.socialsecurity.gov.

To:

Visiting the section “my Social Security” at our web site at www.socialsecurity.gov.

Justification 7: We made this change because of SSA’s addition of “my SSA.”

Change 8: Page 1, “How to Report” section, last bullet—changed the language

From:

Calling, visiting or writing your local Social Security office.

To:

Calling, visiting or writing your local Social Security office at the phone number and address shown on your claim receipt.

Justification 8: We made this change so the language will be consistent for all forms in the package.

Revisions to All Paper Forms
We are revising the PRA Statements on each paper form in this information collection request (ICR) 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 new Privacy Act Statements to each paper form within this ICR.

Changes to the MCS Screens
Due to a policy change, we now require signature proxy (verbal attestation) for every application we enter into the Modernized Claims System (MCS) unless the respondent refuses attestation. We collect information in MCS whenever we conduct a personal interview either in a field office or via telephone for individuals applying for RIB or DIB. If the individual refuses attestation, we print out the MCS summary and request a wet signature from them.

We will start using the new versions of these paper forms and Internet applications immediately after OMB approval.

We will destroy stocks of the old versions of these paper forms.

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Naomi
File Modified	0000-00-00
File Created	2021-01-29