Addendum to the Supporting Statement 0960-0681

ADDENDUM TO THE SUPPORTING STATEMENT FOR

FORM SSA-3373-BK

FUNCTION REPORT-ADULT

20 CFR 404.1512 and 20 CFR 416.912

OMB No. 0960-0681

Revisions to the Collection Instrument

SSA is making the following revision:

We plan to make the following change to SSA-3373 within the first year after approval. We will use the prior paper revision until stock is exhausted.

Change 1: We are adding a penalty warning near the beginning of form SSA-3373. The warning statement reads:

Anyone who makes or causes to be made a false statement or representation of material fact for use in determining a payment under the Social Security Act, or knowingly conceals or fails to disclose an event with an intent to affect an initial or continued right to payment, commits a crime punishable under Federal law by fine, imprisonment, or both, and may be subject to administrative sanctions.

Justification 1: We are adding the statement for fraud deterrence and legal enforcement purposes.

Other Minor Revisions to the Collection Instrument

SSA is making the following revisions:

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 first page of the form.