Addendum to Supporting Statement 0010

Addendum to the Supporting Statement for Form SSA-4-BK

Application for Child’s Insurance Benefits

20 CFR 404-350 – 404.368 and 404.603, CFR 414.350

OMB No. 0960-0010

Minor Revisions to the Collection Instrument

SSA is making the following revisions:

SSA-4-BK

• Change #1: Page 1, Question 3, Column 1 on left side of page: We are revising the third bullet point:

Old Language:

List below all children who are:

• Under age 18

• Age 18 to 19 and attending elementary

or secondary school full-time

• Disabled or Handicapped (age 18 or

over and disability began before age 22)

New Language:

List below all children who are:

• Under age 18

• Age 18 to 19 and attending elementary

or secondary school full-time

• Age 18 or older with a disability that

began before age 22

Justification #1: We made this change to remove the word “handicapped,” which has a negative connotation, and to make the language on the application consistent with the language we use in our publications about benefits for children.

• Change #2: We are revising the language on Page 1, Question 3, Column 5 from the left side of page, which provides the instruction to “Check (X) the Column That Shows Child’s Relationship to Worker”: In the choices available to be checked for how the child is related to the Worker, we replaced “Legitimate” with “Natural.”

Justification #2: We made this change so that the choices in this column align with the first sentence in Question #3, which indicates that the Worker’s children include natural children, adopted children, and stepchildren. It does not specifically address “legitimate” children.

• Change #3: Page 6, Applicant’s Mailing Address: We are revising the address language to begin street with a capital “S”:

Old Language: Applicant’s Mailing Address (Number and street, Apt No., P.O. Box, or Rural Route)

New Language: Applicant’s Mailing Address (Number and Street, Apt No., P.O. Box, or Rural Route

Justification #3: We capitalized “Street” to be consistent with other address fields in the application.

• Change #4: Page 6, “1. Signature of Witness”: We are revising the language to italicize words as follows:

Old Language: Address (Number and Street, City, State, and ZIP Code)

New Language: Address (Number and Street, City, State, and ZIP Code)

Justification #4: We italicized language to be consistent with the look of other address fields in the application.

Change #5: Page 8, language in middle of page, right column: We are revising the language as follows:

Old Language: In the meantime, if you or any child(ren) changes address, or if there is some other change that may affect your claim, you or someone for you should report the change. The changes to be reported are listed below.

New Language: In the meantime, if you or any child(ren) changes address, or if there is some other change that may affect your claim, you or someone for you should report the change. The changes to be reported are listed on Page 9.

Justification #5: We made this revision to provide correct information about where the reader can find changes to be reported. The changes to be reported are not listed below this language. They are listed on Page 9.

Change #6: Page 9, left column, first bullet point: We are revising the language to insert a comma as follows:

Old Language: You or any child changes mailing address for checks or residence. To avoid delay in receipt of checks you should ALSO file a regular change of address notice with your post office.

New Language: You or any child changes mailing address for checks or residence. To avoid delay in receipt of checks, you should ALSO file a regular change of address notice with your post office.

Justification #6: We revised this sentence to correct punctuation.

Change #7: Page 9, under section title “HOW TO REPORT,” first bullet point: We are revising the language:

Old Language: Visiting the section “What You Can Do Online” at our web site at www.socialsecurity.gov;

New Language: Visiting the section “my Social Security” at our web site at www.socialsecurity.gov;

Justification #7: We revised this language because we no longer use “What You Can Do Online” on the www.socialsecurity.gov homepage. The link now reads “my Social Security.”

Change #8: Page 9, under section title “HOW TO REPORT,” fourth bullet point: We are revising the language:

Old Language: Calling, visiting or writing your local Social Security office at the phone number and address above.

New Language: Calling, visiting, or writing your local Social Security office at the phone number and address shown on your claim receipt.

Justification #8: We revised this language to provide proper punctuation for series and correct the location where the reader can find the address and phone number of the local Social Security office.

SSA-4-INST

Change #9: Page 1, right column, under section title “HOW TO REPORT,” first bullet point: We are revising language:

Old Language: Visiting the section “What You Can Do Online” at our web site at www.socialsecurity.gov;

New Language: Visiting the section “my Social Security” at our web site at www.socialsecurity.gov;

Justification #9: We revised this language because we no longer use “What You Can Do Online” on the www.socialsecurity.gov homepage. The link now reads “my Social Security.”

Change #10: Page 1, right column, under section title “HOW TO REPORT,” fourth bullet point: We are revising the language:

Old Language: Calling, visiting or writing your local Social Security office at the phone number and address above.

New Language: Calling, visiting, or writing your local Social Security office at the phone number and address shown on your claim receipt.

Justification #10: We revised this language to provide proper punctuation for the introductory series and to correct the location where the reader can find the address and phone number of the local Social Security office.

• Change #11: We are revising the Privacy Act Statement on this form.

Justification #11: 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.