Addendum - 0759

Addendum to the Supporting Statement for Form SSA-4111

Certificate of Election for Reduced Widow(er)’s and

Surviving Divorced Spouse’s Benefits

20 CFR 404.335

OMB No. 0960-0759

Revisions to the Collection Instrument

SSA is making the following revisions to Form SSA-4111:

• Change #1: In the box, “Enter His or Her Social Security Number”, we are removing “His or Her” and replacing with “Wage Earner’s.”

Justification #1: We are removing gender specific language.

• Change #2: In the first line under, Information About Reduced Widow(er)’s and Surviving Divorced Spouse’s Benefits, we are deleting “widow’s, widower’s” and replacing with “widow(er)’s.

Justification #2: We are revising this language to be consistent with policy and the title of 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  The current language, which dates back to the last reprint of the form, is now outdated.

• 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.