Addendum to Supporting Statement

Addendum to Supporting Statement for Form SSA-58

Modified Benefit Formula Questionnaire-Employer

20 CFR 404.213

OMB No. 0960-0477

Minor Revisions to the Collection Instrument

SSA is making the following revisions:

Change 1: We are removing the word Signature and replacing with “Name”, on page 2.

Justification 1: The pension-paying agency completes this form, and there is no regulatory requirement for a signature.

We will start using the new version upon OMB approval. We can continue to use the old version until we run out of copies and then switch to the new version.

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  The current language, which dates back to the last reprint of the form, is now outdated.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.

We will start using the new version upon OMB approval. We can continue to use the old version until we run out of copies and then switch to the new version.