Addendum - 0015

Addendum to the Supporting Statement for Form SSA-521

Request for Withdrawal of Application

20 CFR 404.640

OMB No. 0960-0015

Minor Revisions to the Collection Instrument

SSA is making the following revisions:

• Change #1: We are revising the language at the bottom of the “Give reason for withdrawal” section:

• Old Language: “Continued on reverse”

• New Language: “See additional remarks”

Justification #1: We are making this language change for clarification purposes.

• Change #2: We are adding the following perjury statement above where the claimant signs:

I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of my knowledge.  I understand that anyone who knowingly gives a false statement about a material fact in this information, or causes someone else to do so, commits a crime and may be subject to a fine or imprisonment.

Justification #2: We added the language above for consistency with language used on our applications for benefits.

• Change #3: We are revising the language in the “For Use of Social Security Administration” section at the bottom of the form:

• Old Language: “Claims Authorizer”

• New Language: “Claims Specialist”

Justification #3: We revised the wording because the agency changed the job title.

• Change #4: We are revising the Privacy Act Statement on this form.

Justification #4: 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 #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  The current language, which dates back to the last reprint of the form, is now outdated.