Addendum - 0229

Addendum to the Supporting Statement for Form SSA-8000-BK

Application for Supplemental Security Income

20 CFR 416.207 & 416.305-416.335, Subpart C

OMB No. 0960-0229

Revisions to the Collection Instrument

SSA is making the following revisions to the SSA-8000-BK:

• Change #1: Page 1 under, “Do not write in this space” section, on the right side of application. We need to update the language to show SNAP.

From:

FS-SSA/App FS-Referred

To:

SNAP-SSA/APP SNAP-Referred

Justification #1: We corrected the term food stamps to reflect the new term Supplemental Nutrition Assistance Program (SNAP).

• Change #2: Page 1, Question #1d - We are removing the terms Mother’s, Father’s, and Maiden name and replacing them with Parent 1, Parent 2, and Other Name(s) (including Name at Birth).

From:

Mother's Father's Name: Go to #2

Maiden Name:

To:

Parent 1’s Name(s) Parent 2’s Name(s)

Parent 1’s Other Name(s) Parent 2’s Other Name(s)

(Including Name at Birth) (Including Name at Birth)

Justification #2: This aligns with our gender-neutral terms.

• Change #3: Page 1, Questions 2 and 3 - We are revising the address sections to include the collection of information for a foreign address (if applicable).

From:

Applicant's Mailing Address (Number & Street, Apt. No. P.O. Box, Rural Route)

City and State ZIP Code County

To:

Applicant's Mailing Address (Number & Street, Apt. No. P.O. Box, Rural Route)

City and State ZIP Code County

State/Province/Region (foreign) Postal Code Country

Justification #3: We are updating the paper form to align with the SSI Claim System.

• Change #4: Page 2, Question 6 - We are adding two new questions regarding holding out. The new questions will become #6c and #6d.

New questions:

#6(c) Are you and another person living together in the same household and presenting to others or the community as a married couple?

YES If yes, provide the date holding out began __________, then go to (d).

NO Go to #7

#6(d) Other person's (First, middle initial, last) and Other person's Social Security Number. *Use SSA-4178 to develop the holding out relationship.

Justification #4: Form SSA-8000-BK does not have the “holding out” question. It appears we never included the holding out question on this form. The Holding Out page of the SSI Claim System web page collects the information about the possible holding out relationship(s) of the person. It also collects the decision about a holding out relationship. We share the information collected on the Holding Out page among all claims where the person’s SSN is active.

The holding out question is not mandatory to answer in the SSI Claim System but the system requires the interviewer to ask that question to an individual filing for SSI benefits when an individual answers “No” to the marriage question. The public may not understand that SSA considers a couple as a “couple” even if they are not legally married.

At the initial claim, we establish the record as an eligible individual; an eligible individual with an ineligible spouse; or an eligible couple. When we ask “are you married” it is likely that the individual assumes legally married only, and only documents the legal marriage information. When asking an SSI individual if they are “holding themselves out” and the answer is “yes,” the SSI Claim System puts the appropriate screens in the path for completion. Currently, the users develop the holding out relationship on the SSA‑4178.

Holding out is part of our policy SI 501.150 and GN 210.800, therefore we show the question on the paper SSA-8000-BK application form.

Although we did not previously include these questions on Form SSA-8000-BK, we already included the burden for these questions in our burden figures.

• Change #5: Page 2, Question 6b - We are updating the “Go to #4” at the end of the sentence to show “Go to #7.” We are also replacing the following language in the sentence: “former” spouse and “former” marriage with the term “prior.”

From:

b) Give the following information about your former spouse. If there was more than one former marriage, show the remaining information in Remarks and go to #4.

To:

b) Give the following information about your prior marriages. If there was more than one prior marriage, show the remaining information in Remarks and go to #7.

Justification #5: We corrected the end of the sentence to show “go to #7,” which is the correct question # that follows question #6. In addition, we updated the language for clarity.

• Change #6: Page 2, Question 7a - We need to update the “Go to #7” to “Go to #8” when selecting “No” under “Your Spouse.”

From:

Your Spouse

YES NO

Go to (b) Go to #7

To:

Your Spouse

YES NO

Go to (b) Go to #8

Justification #6: We updated the option under “NO” to show “go to #8,” which would be the correct question # that follows question #7.

• Change #7: Page 3, Question 7c - We are updating Question 7c.

From:

What are your illnesses, injuries or conditions?

You Go to (d)

Your Spouse Go to (d)

To:

Are you blind or do you have low vision even with glasses or contacts?

You

YES NO Go to (d)

Your Spouse

YES NO Go to (d)

Justification #7: There are special rules for people who are blind or have low vision. We are adding low vision to the blind question to capture claimants who may not consider themselves blind, but have a visual acuity that meets the statutory blindness requirements.

• Change #8: Page 3, Question 7f - We are updating Question 7f.
  
  From:
  What are the child’s disabling illnesses, injuries or conditions?
  YES NO Go to (g)
  
  To:
  Is the child blind or do they have low vision even with glasses or contacts?
  YES NO Go to (g)

Justification #8: There are special rules for people who are blind or have low vision. We are adding low vision to the blind question to capture claimants who may not consider themselves blind, but have a visual acuity that meets the statutory blindness requirements.

• Change #9: Page 3, Question 7(d) & (g) - We are adding additional lines for another parent name, address, and SSN. Currently, there is only space to enter one parent’s information.

Justification #9: Adding additional space will allow respondents to list a second parent’s name, address, and SSN (if needed).

• Change #10: Page 4, Question 11 - We rearranged the order of the current immigration status for You and Your Spouse.

From:

1. Amerasian Immigrant

2. Lawful Permanent Resident

3. Refugee

4. Asylee

5. Conditional Entrant

6. Parolee for One YEAR

7. Cuban/Haitian Entrant

8. Deportation/Removal Withheld

9. Other

To:

1. Amerasian Immigrant

2. Asylee

3. Conditional Entrant

4. Cuban/Haitian Entrant

5. Deportation/Removal Withheld

6. Lawful Permanent Resident

7. Parolee for One YEAR

8. Refugee

9. Unknown/Other

Justification #10: We rearranged the order of questions in this list to match the order in the SSI Claims System.

• Change #11: Page 10, Part 3 Resources - We are adding a new Question 39.
  
  

Justification #11: We added the new question to align with the SSI Claim System. This new question will not increase our burden due to it saving time elsewhere on the form.

• Change #12: Page 12, Question 42(a) - Add another Resource to the list of items:

Achieving a Better Life Experience (ABLE) account.
You: Yes No

Your Spouse: Yes No

Justification #12: We are making the change to align with the SSI Claims System.

• Change #13: Page 13, Question 43(c) - Remove the word Trustee’s from the first column of the chart.

Justification #13: Since we are adding a new question #39 for Trusts only, we no longer need to have the term “Trustee” appear in the first column of the chart.

• Change #14: Page 13, Question 44(b) – We updated the language:

From:

(b) Describe the property (including size, location, and how it is used. If the property is not used now, when was it last used? Do you plan to use the property in the future?

To:

(b) Describe the property (including size, address, and how it is used. If the property is not used now, when was it last used? Do you plan to use the property in the future?

Justification #14: We replaced the word “location” with “address” to obtain the exact address of the property.

• Change #15: Page 13, Question 44(b) - We removed the columns for “Tax Assessed Value” and “Mortgage.”

Justification #15: When taking an SSI claim, we no longer ask the individual for the tax assessed value and mortgage of their non-home real property.

• Change #16: Pages 10-24, Questions 39-64 require renumbering as follows:

• Question #39 renumbered as #40

• Question #40 renumbered as #44

• Question #41 renumbered as #46

• Question #43a renumbered as #42c

• Question #44 renumbered as #41

• Question #46 renumbered as #49

• Questions #49-64 renumbered as #50-65

Justification #16: Realigning the questions on the paper SSA-8000-BK makes these questions consistent with the order in the SSI Claims System.

• Change #17: Page 19, Part 5 Heading and Questions 57(a), (c), & (f) - Replace language term "food stamps" with “Supplemental Nutrition Assistance Program (SNAP).”

Heading
From:

POTENTIAL ELIGIBILITY FOR FOOD STAMPS

To:

POTENTIAL ELIGIBILITY FOR SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP).

Question 57(a)

From:

Are you currently receiving benefits food stamps?

To:

Are you currently receiving SNAP benefits (formerly food stamps)?

Question 57(c)

From:

Have you filed for food stamps in the last 60 days?

To:

Have you filed for SNAP in the last 60 days?

Question 57(f)

From:

May I take your food stamp application today?

To:

May I take your SNAP application today?

Justification #17: We corrected the term food stamps to reflect the new term Supplemental Nutrition Assistance Program (SNAP).

• Change #18: Page 20, Question 58 - We are updating the language to replace the word “father” with “parent.”

Justification #18: We are removing the word “father” and replacing it with the gender‑neutral term “parent.”

• Change #19: Page 20-21, Question 60 - We are adding the following question (c):

Have you ever served as representative payee for a Social Security beneficiary or SSI claimant?

Yes No Go to 62

Justification #19: When we decide to impose an administrative sanction and the individual is not currently entitled or eligible for either Title II or Title XVI benefits, we must defer the sanction period. The sanction period cannot begin until the person becomes entitled or is eligible for a payment under either Title II or Title XVI. Revising Form SSA‑8000-BK to include this question will help us obtain information that allows us to sanction individuals in deferred status.

• Change #20: Page 21, Part 7 Remarks Section - We are increasing the size.

Justification #20: Increasing the space for remarks allows us to collect more information.

• Change #21: Page 23, Reporting Responsibilities - Remove the term “husband/wife.”

From:

Report changes in income of your ineligible husband/wife or child who lives with you or your sponsor or sponsor's spouse, if you are an alien.

To:

Report changes in income of your ineligible spouse or child who lives with you or your sponsor or sponsor's spouse, if you are an alien.

Justification #21: We are removing the term “husband/wife” and replacing it with the gender-neutral term “spouse.”

• Change #22: Page 24, Changes to Report, Bullet 7 - replace “step parent” with “stepparent.”

From:

IF YOU ARE THE PARENT, STEP PARENT, OR REPRESENTATIVE PAYEE FOR A CHILD UNDER 18 - A report to Social Security must be made if:

• There is a change in any income the child, his or her parent(s), step parent, or brother(s) or sister(s) receive.

• There is a change in the student status of the child's brother(s) or sister(s).

• There is a change in his or her parents' or step parents' marriage, a change in the value of anything they own, or a change in their residence.

To:

IF YOU ARE THE PARENT, STEPPARENT, OR REPRESENTATIVE PAYEE FOR A CHILD UNDER 18 - A report to Social Security must be made if:

• There is a change in any income the child, his or her parent(s), stepparent, or brother(s) or sister(s) receive.

• There is a change in the student status of the child's brother(s) or sister(s).

• There is a change in his or her parents' or stepparents' marriage, a change in the value of anything they own, or a change in their residence.

Justification #22: We updated the term “step parent” to “stepparent.” This conforms to how it is written in our policies.

• Change #23: Pages 10-22, renumber questions 39-65 and renumber all ‘Go to #’s’.

Justification #23: Due to the addition of new question 39, we are renumbering questions 40-64 and the Go to #’s on the SSA‑8000-BK.

• Change #24: We are revising the Privacy Act Statement on this form
  
  Justification #24: 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

There are no changes to the SSI Claims System.

We will implement these revisions upon OMB’s approval for this information collection request.

Future Revisions to the Collection Instrument

We are undergoing a substantial redesign of the systems with which we collect information to make determinations on eligibility for, and entitlement to, program benefits, including our applications for benefits. The substantial changes are part of our ongoing IT Modernization efforts. Therefore, we anticipate future changes requiring OMB clearance. We will submit change requests as the system releases progress.