Justification for the Non-Substantive Changes - 0229

Justification for Non-Substantive Change for Form SSA-8000-BK

Application for Supplemental Security Income (SSI)

20 CFR 416.207 & 416.305-416.335, Subpart C

OMB No. 0960-0229

Background

The SSI program provides aged, blind, and disabled individuals who have little or no income with funds for food, clothing, and shelter. Individuals either complete Form SSA-8000-BK using the paper form, or via personal interview with a claims representative using the electronic Modernized SSI Claims System (MSSICS) to apply for SSI. SSA uses the information gathered from the SSA 8000-BK to: (1) determine whether claimants meet all statutory and regulatory requirements for SSI eligibility; and (2) calculate SSI payment amounts. The respondents are SSI applicants or their representative payees.

In November 2016, we received OMB approval for the removal of question #19 from the SSA-8000-BK form. In the clearance package, we inadvertently did not include the renumbering of the questions on the form after removing question #19.

To address this issue in a timely matter, we are requesting to renumber the questions and the Go to # on the SSA-8000-BK form now, instead of waiting for the renewal time.

Revision to the SSA-8000-BK:

• Change #1: Pages 6-21: Renumber questions 20-65 to show 19-64 and renumber all ‘Go to #’s’.

Justification #1: Due to the removal of question #19, we are renumbering questions 20-65 and the Go to #’s on the SSA‑8000-BK.

This action does not affect the public reporting burden.