Addendum to Supporting Statement

Addendum to the Supporting Statement for Form SSA-8001-BK

Application for Supplemental Security Income (SSI)

(Deferred or Abbreviated)

20 CFR 416.305 - 20 CFR 416.335, Subpart C

OMB No. 0960-0444

Revisions to the Collection Instrument

Below is a summary of changes for SSA-8001-BK. These revisions are to clarify and update minor changes in policy. There are no required changes for the Modernized Supplemental Security Income Claims System (MSSICS).

Change 1: We made changes to Question 5. We broke down the question into three subsections (a), (b), and (c).

The old version was: Spouse’s/Parent(s) Name(s)

The new version is:

If filing as spouse or couple

5(a) Spouse’s Name(s)

If filing for child

(b) Parent 1’s Name(s)

If filing for child

(c) Parent 2’s Name(s)

Justification 1: We separated the question for clarity.

Change 2: We made changes to Question 6. We added subsections (a), (b), and (c) to include selections for gender in each corresponding response to question #5 (a), (b), and (c).

Justification 2: We separated the question for clarity.

Change 3: We made changes to Question7. We added subsections (a), (b), and (c) to indicate the birthdate for the corresponding response to question #5 (a), (b), and (c).

Justification 3: We separated the sections to show the corresponding response to question 5 (a), (b), and (c).

Change 4: We made changes to Questions 8. We added subsections (a), (b), and (c) to indicate the Social Security Number for the corresponding response to question #5 (a), (b), and (c).

Justification 4: We separated the sections to show the corresponding response to question #5 (a), (b), and (c).

Change 5: We revised Question 9.

• Old language

Other Name(s) and Social Security Number(s) you, your spouse/parents used:

• New language:

Other Name(s) and Social Security Number(s) you or your spouse used. If filing for child benefits go to (c) and (d):

Justification 5: We separated the question for clarity to show when the answer is for spouses or children.

Change 6: We revised Question #9 (a), (b) and (c). We broke down the question for clarity and added subsection (d).

• Old language:

(a) Your Other Name(s) (including Maiden Name) Your Other Social Security Number(s)

(b) Spouse’s/Mother’s Other Name(s) (including Maiden Name) Spouse’s/Mother’s Other Social Security Number(s)

(c) Father’s Other Name(s) Father’s Other Social Security Number(s)

• New language:

(a) Your Other Name(s) (including Name at Birth) Social Security Number(s)

(b) Spouse’s Other Name(s) (including Name at Birth) Social Security Number(s)

(c) Parent 1’s Other Name(s) (including Name at Birth) Social Security Number(s)

(d) Parent 2’s Other Name(s) (including Name at Birth) Social Security Number(s)

Justification 6: We separated the question for clarity.

Change 7: We revised Question 21 (a) –

• Old language:

Do you have any unsatisfied felony warrants for your arrest?

• New language:

Do you have any felony arrest warrants for escape from custody, flight to avoid prosecution or confinement, or flight escape?

Justification 7: We update this question to reflect a policy change based on the Martinez Settlement. The Martinez Settlement is a nation-wide class action settlement that caused us to no longer suspend and deny payments 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.

Change 8: We revised Question 22 (a).

• Old language:

Do you have any unsatisfied Federal or state warrants for violating the conditions of probation or parole?

• New language:

Have you violated a condition of your probation or parole under Federal or State laws?

Justification 8: We updated this question to reflect a policy change based on the Clark Court Order requiring that we no longer suspend or deny payments based on an outstanding probation or parole violation warrant.

Change 9: We revised Question 22 (b) - We removed “Country” from the required field.

Justification 9: We revised this question because we can only use a U.S. Federal or State probation or parole system within the United States.

Change 10: Question #22 (c) - We deleted the question, “Was the warrant satisfied?”

Justification 10: We revised this question due to the Clark Court Order requiring that we no longer suspend or deny payments based on an outstanding probation or parole violation warrant.

Change 11: Question #22 (d) – We reworded and renumbered the question from:

(d) Date warrant satisfied:

To:

(c) Date of violation:

Justification 11: We revised this question due to the Clark Court Order requiring that we no longer suspend or deny payments based on an outstanding probation or parole violation warrant.

Change 12: Question #26 - We rearrange the items (a) thru (h) and deleted “Life Estates” from the list. We also added question (f) “Items held for potential value or investment (for example, coin or card collection, jewelry in safe deposit box)”.

Justification 12: We revised this section to group the information based on category. We deleted “Life estates” because it is asked in “Other resources”. We added question (f) to account for items with potential value.