Addendum to the Supporting Statement for 0960-0003

Addendum to Supporting Statement for Form SSA-5-BK

Application for Mother’s or Father’s Insurance Benefits

20 CFR 404.339 - 404.342, 20 CFR 404.601 - 404.603

OMB No. 0960-0003

Revisions to the Collection Instrument – Form SSA-5-BK

• Change #1: We are removing question #10(a), “Have you (or has someone on your behalf) ever filed an application for Social Security, Supplemental Security Income, or hospital or medical insurance under Medicare?”, question #10(b), “Enter name of person(s) on whose Social Security record you filed other than application.”, and question #10(c), “Enter Social Security number(s) of person named in (b)”. We do not believe that removing these questions will cause a decrease in the average burden per response since the questions take less than a minute to complete.

Justification #1: We are removing these questions because we are not required to ask individuals these questions since the information is already in SSA records. The data fields for these questions will remain in the Modernized Claim System (MCS). Technicians will complete the data fields with information they obtained from SSA records.

• 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.

Change #3: We are revising the PRA statement on this form.

Justification #3: 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  The current language, which dates back to the last reprint of the form, is now outdated.

SSA will implement these revisions upon OMB’s approval. These revisions do not affect the burden for this information collection.

Preliminary Claims System (PCS)

• Change #4: We are removing the PCS as a collection tool for application questions that we added with the March 2019 Change Request.

Justification #4: Due to reassessing IT Modernization initiatives, we stopped development for the PCS. The focus shifted to creating the Consolidated Claims Experience (CCE), which will replace our current legacy claim system with web-based claims. We will submit the new CCE screens to OMB via Change Request, once we have them ready.