Addendum to Supporting Statement 0784

Addendum - 0784.docx

Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event

Addendum to Supporting Statement 0784

OMB: 0960-0784

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Addendum to the Supporting Statement for Form SSA-44

Medicare Income-Related Monthly

Adjustment Amount – Life-Changing Event

20 CFR 418.1205, 418.1255, 418.1265, 418.2205, 418.2255, 418.2265

OMB No. 0960-0784


Minor Revisions to the Collection Instrument


SSA is making the following revisions:


  • Change #1: We are revising the PRA statement on this form.


Justification #1: 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  The current language, which dates back to the last reprint of the form, is now outdated.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 #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.

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleAddendum to the Supporting Statement for Form SSA-3462
Author177717
File Modified0000-00-00
File Created2021-01-13

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