Addendum to the Supporting Statement 0960-0579

Addendum to the Supporting Statement for the SSA-3368

Disability Report – Adult

20 CFR 404.1512 and 416.912

OMB No. 0960-0579

Revisions to the Collection Instrument

We plan to make all of the following changes to i3368 and SSA-3368 within the first year after approval. We will use the prior paper version until stock is exhausted.

Change 1:

We are adding a penalty warning near the beginning of Form SSA-3368 and the i3368. The warning statement reads:

Anyone who makes or causes to be made a false statement or representation of material fact for use in determining a payment under the Social Security Act, or knowingly conceals or fails to disclose an event with an intent to affect an initial or continued right to payment, commits a crime punishable under Federal law by fine, imprisonment, or both, and may be subject to administrative sanctions.

Justification 1:

We are adding the statement for fraud deterrence and legal enforcement purposes.

Change 2:

We are changing the dollar amount in questions #4.E and #4.G to “$1,090.”

Justification 2:

We are making this change to reflect the 2015 Non-Blind Disabled Substantial Gainful Activity (SGA) amount as contained within §§404.1571 through 404.1576 and 416.971 through 416.976.

Change 3:

We are changing the instructions in section 8 by removing the last 6 words from each of four duplicative sentences as follows:

Tell us who may have medical records about any of your physical and/or mental condition(s) (including emotional or learning problems) that limit your ability to work.

Justification 3:

We are making this change for consistency with our regulations published March 20, 2015 at 80 FR 14828. Our regulations, effective April 20,2015, require claimants to inform the Social Security Administration about or submit all evidence known to the claimant that relates to whether or not the claimant is blind or disabled as contained within §§404.1512 and 416.912.

Other Minor Revisions to the Collection Instrument

SSA is making the following revisions:

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 i3368 Internet application.

We are revising the completion time estimate on the Paperwork Reduction Act Statement to 90 minutes on the SSA-3368 and the EDCS collection instruments.