Addendum to the Supporting Statement for 0960-0142

Addendum to the Supporting Statement for Form SSA-721

Statement of Death by Funeral Director

20 CFR 404.715 and 404.720

OMB No. 0960-0142

Minor Revisions to the Collection Instrument

SSA is making the following revisions:

• Change #1: We are adding page numbers to the form.

Justification #1: The SSA-721 is three pages. Adding page numbers aligns with our other SSA forms.

• Change #2: Page 1, top of page. We are removing the blocks ‘Name of Deceased” and “Social Security number.”

Justification #2: We are removing these two redundant fields. The name of the deceased and social security number already appear on page 1 under block 1 and block 2.

• Change #3: Page 1, We are making the address section fillable.

Justification #3: We are making the address field fillable to allow for easier completion of the form.

• Change #4: Page 1, We are updating the sentence:

Old Language: Please complete the items below, and return the form in the enclosed addressed, postage paid envelope. Your assistance and cooperation are appreciated.”

New Language: "Please complete the required fields (*) below. Send the completed form to your local Social Security (SS) Office. Please give pages 2 and 3 of this form to any survivors of the deceased. Note: If reporting the death through Electronic Death Registration (EDR), the SSA-721 does not need to be sent to SS. Your assistance and cooperation are appreciated."

Justification #4: We updating instructions for completing the form and returning to local Social Security office. If the funeral director is using EDR, it is redundant to complete the SSA-721.

• Change #5: We are moving the Privacy Act and Paperwork Reduction Act Statements to the end of the form.

Justification #5: Moving the statements to the bottom of the form aligns with the location of those statements on our other forms.

• Change #6: Page 1, block 1: We are adding (First, Middle, Last, Suffix) after name of deceased.

Justification #6: The funeral director needs to provide the full name of the deceased including middle name. Our system requires the name to be a perfect match before we can terminate a Numident.

• Change #7: Page 1. We are adding a new field (1a) for “Other names use, (if known).”

Justification #7: We are adding a new field to allow for additional names of the deceased in the event that there has been additional marriages or divorces and the deceased name was never updated with SSA.

• Change #8: We are adding asterisks (*) for the required fields (blocks 1-5 and name, address, signature, and phone of funeral director) to be completed on the SSA-721 form.

Justification #8: Having the required fields marked will assist in processing the form.

• Change #9: Page 1, block 2. We are adding the statement: “If SSN is unknown, contact SSA to report death.”

Justification #9: An SSN is required to be an acceptable proof of death.

• Change #10: Page 1, block 3: We are adding a new field (3a) to list the City/State/Country where the death occurred.

Justification 10: Providing the City/State/Country where the death occurred will be helpful in knowing which state Vital Records department to contact if there are issues with a death certificate or the death information submitted. Survivor claims are handled based on the state of death.

• Change #11: Page 1, block 4: We are adding a new field (4a) to list the City/State/Country of Date of Birth.

Justification 11: Providing the City/State/Country of Birth will assist with an ALPHIDENT search if necessary to verify the correct deceased individual.

• Change #12: Page 1, Block 6 and 7: We are updating terms “Widow/Widower” to “Surviving Spouse.”

Justification 12: We are updating these terms to be consistent with gender-neutral policy

used on other SSA forms.

• Change #13: Page 1, block 6: We are adding a new field (6a) to list the surviving spouse’s SSN.

Justification 13: Providing the surviving spouse’s SSN will help reduce errors (i.e. family gave the surviving spouse’s SSN instead of the deceased SSN) when processing the SSA‑721.

• Change #14: Page 1, block 6: We are changing “if known” to “if not applicable, names of any minor or disabled children, (if known).”

Justification 14: Adding a field for the names of any minor or disabled children if there is no surviving spouse creates a potential lead for survivor benefits that we must address and close out properly. In addition, this information is helpful in the event that there is an underpayment on the deceased record.

• Change #15: Page 1, block 7: We are changing “if known” to “if not applicable, addresses of any minor or disabled children, (if known).”

Justification 15: Adding a field for the addresses of any minor or disabled children if there is no surviving spouse creates a potential lead for survivor benefits that we will address and close out properly. In addition, this information is helpful in the event that there is an underpayment on the deceased record.

• Change #16: Page 1, bottom of page: We are updating “DO” Processed (Date) to “DO/FO Processed (Date).”

Justification 16: Updated to include Field Office (FO) as not all FOs that process these forms are District Offices (DO).

• Change #17: Page 2: We are updating the paragraph: “A Message from Social Security” as follows:

From:

To:

Your funeral director is helping the Social Security Administration by providing you information about your Social Security benefits. If the deceased was receiving benefits, contact us to report the death. If you think you may be eligible for survivor benefits, contact us to apply.

Justification 17: We removed and updated some of the language in the sentence to provide clarity.

• Change #18: Page 2: We are updating “How Social Security Helps Families” as follows, and removing the indentation of the word “anyone” in the second paragraph.

Old Language:

New Language:

Social Security survivor benefits help ease the financial burden that follow a worker’s death. Almost all children under age 18 will get monthly benefits if a working parent dies. Other family members may be eligible for benefits too.

Anyone who has worked and paid Social Security Federal Insurance Contributions Act (FICA) has been earning Social Security benefits for their family. The amount of work needed to pay survivor benefits depends on the worker’s age at the time of death. It may be as little as 1 to 1.5 years for a young worker. No one needs more than 10 years.

Justification 18: We are removing and updating some of the language in the paragraph to provide clarity.

• Change #19: Page 2: We are updating the paragraph: “Who Can Get Survivors Benefits?” as follows:

Old Language;

New Language:

Here is a list of family members who are typically eligible for benefits:

• Surviving spouses age 60 or older.

• Surviving spouses at any age if caring for the deceased’s child(ren) who are under age 16 or disabled.

• Divorced spouses age 60 or older, if married to the deceased 10 years or more.

• Surviving spouses and divorced spouses age 50 or older, if they are disabled.

• Children up to age 18.

• Children age 18-19, if they attend elementary school or high school full time.

• Children over age 18, if they became disabled before age 22.

• The deceased worker’s parents age 62 or older, if they were being supported by the worker.

Justification 19: We are updating these terms to be consistent with gender-neutral policy

used on other SSA forms.

• Change #20: Page 2: We are updating the paragraph: “A Special One-Time Payment” as follows:

Old Language:

New Language:

In addition to the monthly benefits for family members, a one-time lump sum death payment of $255 can be paid to a spouse who was living with the worker at the time of the death. If there is none, it can be paid to :

• A spouse who is eligible for benefits.

• A child or children eligible for benefits.

This payment cannot be made if there is no eligible spouse or child.

Justification 20: We are updating the language to include the name of the one-time payment.

Change #21: Page 2-3: We are updating the paragraph: “How to Apply for Benefits” and removing the indentation of the word “If” in the second paragraph:

Old Language:

New Language:

How to sign up for Social Security benefits depends on whether or not you are receiving other Social Security benefits.

If you are not receiving Social Security benefits, you can apply for benefits by telephone, by accessing the Social Security website www.socialsecurity.gov or by going to any local Social Security office. You may need some of the documents shown on the list below. Do not delay your application because you do not have all the information. If you do not have a document you need, the Social Security Administration can help you obtain it.

In many situations if you are already receiving benefits as a spouse on your spouse's record when they pass away, we can automatically change your payments to survivors benefits once the death is reported to us. Benefits for any children will also automatically be changes to survivors benefits once the death is reported to us.

Justification 21: We are removing and updating some of the language in the paragraph to provide clarity. We are updating terms to be consistent with gender-neutral policy used on other SSA forms. We added the SSA website link.

• Change #22: Page 3: We are updating the paragraph: “Information Needed” as follows:

Old Language:

New Language:

• Your Social Security Number and the deceased worker's Social Security Number.

• A death certificate. (Generally, the funeral director provides a statement that can be used for this purpose.)

• Proof of the deceased worker's earnings for the previous year (W-2 forms or self-employment tax return).

  • Your birth certificate.

• A marriage certificate, if you are applying for benefits as a surviving spouse or divorced spouse.

• A divorce decree, if you are applying for benefits as a divorced spouse.

• Children's birth certificates and Social Security Numbers, if applying for children's benefits.

• Your checking or saving account information, for direct deposit of your benefits.

You will need to submit original documents or copies certified by the custodian of records. You can mail or bring them to the Social Security office. Social Security will make photocopies and return the document to you.

Justification 22: We are removing and updating some of the language in the paragraph to provide clarity. We are updating terms to be consistent with gender-neutral policy used on other SSA forms.

• Change #23: Page 3: We are updating the paragraph “Supplemental Security Income (SSI)” as follows:

Old Language:

New Language:

If you are 65 or older, disabled or blind and have limited income and resources, ask the Social Security representative about Supplemental Security Income (SSI). If you received SSI, you may qualify for Medicaid, Supplemental Nutrition Assistance Program (SNAP) and other social services.

Justification 23: We are removing and updating some of the language in the paragraph to provide clarity. We replaced the term “food stamps” with “SNAP.”

• Change #24: Page 3: We are updating the paragraph “For More Information” as follows.

Old Language:

New Language:

For more information visit Social Security's website at www.socialsecurity.gov.

You can also phone the toll-free number at 1-800-772-1213 (TTY 1-800-325-0778). By calling the 800 Number, you can use our automated telephone services to get recorded information and conduct some business 24 hours a day. You can speak to a Social Security representative between 7 a.m. and 7 p.m. Monday through Friday. You can also write or visit any Social Security office. To find your local office, visit our Social Security Office Locator at www.socialsecurity.gov.

Justification 24: We are updating the paragraph to provide additional SSA contact information

• Change #25: Page 3. We are updating the paragraph “A Reminder” as follows:

Old Language:

New Language:

If the deceased received Social Security benefits, return any checks , which arrive after death, to the Social Security office.

If Social Security checks were being directly deposited into a bank account, please notify the bank of the death.

Justification 25: We are removing and updating some of the language in the paragraph to provide clarity.

• Change #26: We are revising the PRA statement on this form.

Justification #26: 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 #27: We are revising the Privacy Act Statement on this form.

Justification #27: 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.

We will implement these revisions upon OMB’s approval. None of these revisions affect the burden estimates for this information collection.