Addendum to Supporting Statement for 0960-0695

Addendum to the Supporting Statement for Form SSA-1021

Request an Appeal of Determination for Extra Help with

Medicare Prescription Drug Costs

OMB No. 0960-0695

Revision to the Collection Instrument

We are proposing the following minor, non-substantive changes to the form:

• Change # 1: We updated a portion of the return address to mail completed forms from the Wilkes-Barre Data Operations Center to the Wilkes-Barre Direct Operations Center.

Justification #1: The agency updated the return address for this workload.

• Change #2: We are revising the Privacy Act Statement on this form.

Justification #2: 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 form.

Revision to the Collection Instrument Instructions

We are making the following revision to the SSA-1021-INST instructions:

• Change #1: We updated question eight with the updated return address to mail the completed form from Wilkes-Barre Data Operations Center to the Wilkes-Barre Direct Operations Center.

Justification #1: The agency updated the return address for this workload.

We will continue to use old forms until stock runs out, then we will print new ones. We will update the fillable PDF and the Intranet screens upon OMB’s approval.