Addendum to Supporting Statement

Addendum to Supporting Statement for Form SSA-5-BK

Application for Mother’s or Father’s Insurance Benefits

20 CFR 404.339 - 404.342, 20 CFR 404.601 - 404.603

OMB No. 0960-0003

Revisions to the Collection Instrument – Form SSA-5-BK

Change 1: We made changes to the language in the application information section directly under the title.

Current language:

“I apply for all insurance benefits for which I am eligible under Title II (Federal Old-Age, Survivors, and Disability Insurance) and Part A of Title XVIII (Health Insurance for the Aged and Disabled) of the Social Security Act, as presently amended.

The information you furnish on this application will ordinarily be sufficient for a determination on the lump-sum death payment. For additional information about this application, a fact to Form SSA-5 is available at www.socialsecurity.gov.

*This may also be considered an application for survivors benefits under the Railroad Retirement Act and for Veterans Administration payments under title 38 U.S.C., Veterans Benefits, Chapter 13 (which is, as such, an application for other types of death benefits under title 38).”

New language:

“With this application, you are applying for all insurance benefits for which you are eligible under Title II (Federal Old-Age, Survivors, and Disability Insurance) and Part A of Title XVIII (Health Insurance for the Aged and Disabled) of the Social Security Act, as presently amended. The information you furnish on this application will ordinarily be sufficient for a determination on the lump-sum death payment.

*This may also be considered an application for survivors benefits under the Railroad Retirement Act and for Veterans Administration payments under Title 38 U.S.C., Veterans Benefits, Chapter 13 (which is, as such, an application for other types of death benefits under Title 38).”

Justification 1: We revised this statement for the following reasons: (1) to fix grammar (the current statement is a mix of first person and third person language) (2) to remove a reference to a fact sheet that no longer exists (3) to increase ease of reading.

Change 2: Page 1 – we made editorial and formatting revisions to

Items 1 – 5. Changes include: (1) capitalizing text (2) correct spacing (3) in the text before Item 5, replace the word “such” with “the” (4) Item 5 – revise “Months child lived….” to “Months and Year child lived….”

Justification 2: The minor editorial revisions reflect the appearance of other recently updated and approved forms in a similar format (e.g., SSA-10). We made revisions to the language for Item 5, because the electronic version of the SSA-5-BK on the Modernized Claim System (MCS) screen path asks for the year as well as the months the child lived with the applicant.

Change 3: Page 2 – we made editorial and formatting revisions to

Items 6 – 11. Changes include: (1) Item 6 (b) – change “person” to “person(s)” and add in the blank space across: “FIRST NAME, MIDDLE INITIAL, LAST NAME” (2) capitalizing text (3) correct spacing (4) Item 10 – replace the word “become” to “became” and revise the statement under the “Yes” check box to: (If “Yes,” enter the name and address of the parent(s) in “Remarks” on page 5)

Justification 3: The minor editorial revisions reflect the appearance of other recently updated and approved forms in a similar format (e.g., SSA-10). The word “become” was replaced with “became” because it was grammatically incorrect. We also revised the statement under the “Yes” check box to clarify what page the respondent should document the requested information.

Change 4: Page 3 – we made editorial and formatting revisions to

Items 11(c) – 12. Changes include: (1) capitalizing text (2) correct spacing

(3) Item 11(c) – revised text about using “Remarks” space to include “PAGE 5” (4) Item 12 – revised text about using “Remarks” space to include “PAGE 5” and deleted the extra free text lines.

Justification 4: The minor editorial revisions reflect the appearance of other recently updated and approved forms in a similar format (e.g., SSA-10). We revised the text in Item 11(c) and 12 about using “Remarks” to clarify what page the respondent should document the requested information. We removed the extra free text lines here to streamline the application. Now, the respondent can document any additional information in the “Remarks” section on Page 5 or attach a separate sheet.

Change 5: Page 4 – we made editorial and formatting revisions to

Items 13 – 14. Changes include: (1) capitalizing text (2) correct spacing (3) revise text: “IF YOU ARE APPLYING….” (4) revise text: “ANSWER ITEM 14 ONLY….” (5) removed extra free text lines (carried over from Page 3, “Remarks” section)

Justification 5: The minor editorial revisions reflect the appearance of other recently updated and approved forms in a similar format (e.g., SSA-10). We revised the text “IF YOU ARE APPLYING….” and “ANSWER ITEM 14 ONLY….” to make the language consistent with other sections of the form and also clarify what question the respondent should answer if the current question is not applicable. We removed the extra free text lines to streamline the application.

Change 6: Page 5 – we made editorial and formatting revisions to Items 15 - 18. Changes include: (1) moved Items 15 – 18 to newly revised Page 4 (removal of the extra free text lines allowed for all the earnings information to be displayed on the same page) (2) revised text: “ANSWER THIS ITEM ONLY….” (3) moved the “Remarks” section to the top half of revised Page 5.

Justification 6: The revisions streamline the appearance of the form and reflects the updates to recently approved forms in a similar format (e.g., SSA-10). As a result of removing the extra free text space on the prior Page 3 and Page 4, one page was eliminated from the revised form all together. We revised the text, “ANSWER THIS ITEM ONLY….” to clarify what question or item form is referring to.

Change 7: Page 6 – we made editorial and formatting revisions. Changes include: (1) moved the penalty of perjury statement, applicant signature, direct deposit, and witness signature sections to the newly revised Page 5 (underneath the “Remarks” section) (2) moved the direct deposit section above the applicant signature and address section (3) deleted “OFFICIAL USE ONLY” block

(4) moved the penalty of perjury statement below the direct deposit section and above the signature and address sections (5) revised the checking and savings account block section – moved this before the “Depositor Account Number” block section and separate “Checking” and “Savings” (6) revised the heading “Depositor Account Number” section to simply “Account Number (7) revised “No account” check block to “Enroll in Direct Express” (8) revised “Applicant’s Mailing Address” statement

Justification 7: The revisions streamline the appearance of the form and reflects the updates to recently approved forms in a similar format (e.g., SSA-10). As a result of removing the extra free text space on Page 3 and Page 4, one page was eliminated from the revised form all together. We also moved the direct deposit section to include the applicant’s answers under the penalty of perjury clause. We revised the “Applicant’s Mailing Address” statement to clarify where the respondent should document the requested information (“Remarks” section on Page 5).

Change 8: Page 7 – we made editorial and formatting revisions. Changes include: (1) moved the Privacy Act Statement and the Paperwork Reduction Act Statement after the “RECEIPT FOR YOUR CLAIM….” section and before “CHANGES TO BE REPORTED….” section (2) the information on current Page 7 now appears on the revised Page 6

Justification 8: The revisions reflect the appearance of other recently updated and approved forms in a similar format (e.g., SSA-10). It will help the respondent to see these sections appear consistently in various forms.

Change 9: Former Page 8 – we made editorial and formatting revisions. Changes include: (1) moved the “RECEIPT FOR YOUR CLAIM….” to the revised Page 6 (2) revised the language: “Always give us your claim number when writing or telephoning about your claim.” to “Always give us your claim number when writing or calling about your claim.” (3) revised “SOCIAL SECURITY NUMBER” to “SOCIAL SECURITY CLAIM NUMBER”

Justification 9: The revisions reflect the appearance of other recently updated and approved forms in a similar format (e.g., SSA-10). We simplified the language, “Always give us your claim number when writing or calling about your claim” for ease of reading. We revised “SOCIAL SECURITY NUMBER” to reflect changes on recently updated forms.

Change 10: Former Page 8 - “CHANGES TO BE REPORTED” is now on the revised Page 7.

Justification 10: The revisions reflect the appearance of other recently updated and approved forms in a similar format (e.g., SSA-10). As a result of removing extra free text space on Page 3 and Page 4, one page was eliminated from the revised form all together (one page less than the prior version).

Change 11: Former Page 8 – we revised the language, “Change of Marital Status – Marriage, divorce, annulment of marriage. You must report marriage even if you believe that an exception applies.” The new language is: “Change of Marital Status – Marriage, divorce, annulment of marriage. You must report a change in marital status even if you believe that an exception applies.” This is now on the revised Page 7.

Justification 11: We revised this language because the original language only stated the need for the respondent to report a marriage, while we require respondents to report any change in marital status.

Change 12: Former Page 8 – we revised the language, “You are confined to jail, prison, penal institution or correctional facility or conviction of a crime or you are confined to a public institution by court order in connection with a crime.” The new language is: “You are confined to jail, prison, penal institution or correctional facility for more than 30 continuous days for a conviction of a crime or you are confined for more than 30 continuous days to a public institution by a court in connection with a crime.” This is now on the revised Page 7.

Justification 12: We made these revisions because the Social Security Act specifically states “more than 30 continuous days” for Title II prisoner and fugitive felon suspensions.

Change 13: Former Page 8 – we revised the language, “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 crimes as felonies, a crime that is punishable by death or imprisonment for a term exceeding 1 year).” The new language is: “You have an unsatisfied warrant for more than 30 continuous days for your arrest for a crime or attempted crime that is a felony or 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 1 year (regardless of the actual sentence imposed). This is now on the revised Page 7.

Justification 13: This change is necessary because of the Martinez Settlement that caused Social Security to no longer suspend benefits for an outstanding felony warrant unless the warrant was issued for a crime or attempted crime of flight to avoid prosecution or confinement, escape from custody and flight-escape. We also added “more than 30 continuous days” because the Social Security Act specifically sates this for Title II prisoner and fugitive felon suspensions.

Change 14: Former Page 8 – we revised the language, “You have an unsatisfied warrant for violation of probation or parole under Federal or State law.” The new language is: “You violated for more than 30 continuous days a condition of your probation or parole under Federal or State law.” This is now on the revised Page 7.

Justification 14: We made these revisions because the Social Security Act specifically states “more than 30 continuous days” for Title II prisoner and fugitive felon suspensions. Also, this change is necessary due to the Clark Court Order requiring that we no longer suspend benefits based on an outstanding probation or parole violation warrant.

Change 15: Former Page 8 – Under “WORK AND EARNINGS” section, deleted text, “…required by law and adjust benefits under the earnings test.” This is now on the revised Page 7.

Justification 15: The revisions reflect the changes of other recently updated and approved forms in a similar format (e.g., SSA-10). It was also updated for ease of reading.

Change 16: Former Page 8 – Under “HOW TO REPORT” section, added bullet: “Visiting the section “What You Can Do Online” at our web site at www.socialsecurity.gov;” This is now on the revised Page 7.

Justification 16: We added this bullet to promote the use of our online services and it also reflects the change made to other recently updated and approved forms in a similar format (e.g., SSA-10).

Minor Revisions to the Collection Instrument

SSA is making the following revisions:

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 are attaching a copy of the revised Paper Work Reduction and Privacy Act Statement in ROCIS. We are making this form fillable format.