Addendum to the Supporting Statment 0960-0707

Addendum to Supporting Statement for

Medicare Subsidy Quality Review Forms

Forms SSA-9301, -9302, -9303, -9304, -9308, -9310,

-9311, -9312, - 9313, -9314 -8510

OMB No. 0960-0707

Minor Revisions to the Collection Instrument

SSA is making the following revisions:

• Change #1: We removed unnecessary wording from the Family Size Interview column and added wording to clarify what we need for the household size and income.

Justification #1: We are making the SSA-9301 more user friendly for the reviewer. The meaning of the questions remains the same. The reformatting on the form makes it more straightforward for the reviewer to administer.

• Change #2: We added clarifying language for the Unearned Income (UI) Verification column. In the Conclusion column, we added new entries to obtain a subtotal and exclusion amount.

Justification #2: We are making the SSA-9301 more user friendly for the reviewer. The meaning of the questions remains the same. The reformatting on the form makes it more straightforward for the reviewer to administer.

• Change #3: In the Earned Income (EI) Conclusion column, we added new entries to obtain a subtotal and exclusion amount.

Justification #3: We are making the SSA-9301 more user friendly for the reviewer. The meaning of the questions remains the same. The reformatting on the form makes it more straightforward for the reviewer to administer.

• Change #4: Due to reviewer confusion, we are reinstating the No check boxes on the Facesheet; Marital Status; Family Size; Liquid Resources; Non-Home Real Property; Funeral/Burial Expenses; Total Countable Resources Summary; Unearned Income; and Earned Income portions of the form. We are also reinstating Yes check boxes as applicable for the same reason.

Justification #4: We are making the SSA-9301 more user friendly for the reviewer. The meaning of the questions remains the same. The reformatting on the form makes it more straightforward for the reviewer to administer.

• Change #5: We are revising the PRA statement on this form.

Justification #5: 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  The current language, which dates back to the last reprint of the form, is now outdated.

• Change #6: We are revising the Privacy Act Statement on this form.

Justification #6: 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 for