Addendum - 0696

Addendum to the Supporting Statement for

Form SSA-1020/i1020

Application for Extra Help with

Medicare Prescription Drug Plan Costs

OMB No. 0960-0696

Revisions to the Collection Instrument

SSA is making the following revisions to Form SSA-1020:

• Change #1: We are clarifying the term Extra Help by inserting the words (a Medicare Part D subsidy).

Justification #1: We are clarifying to align the term Extra Help on the cover page with page #7 Privacy Act language reference to the term Medicare Part D subsidy.

• Change #2: We are updating the agency URL displayed on Page 1, under the heading titled Completing Your Application, from www.socialsecurity.gov to www.ssa.gov.

Justification #2: We are updating the URL link to align the way the agency displays the URL on forms with the way the agency displays the URL in agency publications.

• Change #3: We are adding the following language on Page 3, Question 5: “Do NOT place an X in the spouse NO box if you did not provide spouse information in Question 2.”

Justification #3: We are making this change to clarify instructions. This will reduce the number of spouse-related exceptions generated when the spouse box is checked here but the applicant fails to indicate a spouse in Question 2.

• Change #4: We are adding the following language on Page 5, Question 13: “Do NOT fill in the boxes next to SPOUSE if you did not put spouse information in Question 2.”

Justification #4: We are making this change to align with agency writing guidelines and clarify instructions. This will help reduce the number of spouse-related processing exceptions generated when applicants fill in dates for a spouse in this question but fail to indicate a spouse in Question 2.

• Change #5: We are removing the “NO” box on Page 3 number 14, and adding the following language: “Instructions: if NO, skip to question 15. If YES, place an X in the YES box then go to question 15. Do NOT fill in the boxes next to SPOUSE if you did not put spouse information in Question 2.”

Justification #5: We are updating this language to help reduce the number of erroneous processing exceptions generated when applicants check both the “YES” and “NO” box for either the applicant or the applicant’s spouse.

SSA will implement the changes above upon OMB approval.

These actions do not affect the public reporting burden.

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