Addendum to Supporting Statement

Addendum to Supporting Statement for Form SSA-8019-U2

Third Party Liability Information Statement

42 CFR 433.136-433.139

OMB No. 0960-0323

Minor Revisions to the Collection Instrument

SSA is making the following revisions:

We are updating the language of the penalty/perjury clause on the form.

• Old Language - I know that anyone who makes or causes to be made a false statement or presentation of material fact in an application or for use in determining a right to payment under the Social Security Act commits a crime punishable under Federal law and/or State law.  I affirm that all information I have given in this document is true.

• New Language - 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 or misleading statement about a material fact in this information, or causes someone else to do so, commits a crime and may be sent to prison, or may face other penalties, or both.

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  The current language, which dates back to the last reprint of the form, is now outdated.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’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 of the form.