Addendum to the Supporting Statement for 0960-0395

Addendum to the Supporting Statement for Form SSA-150

Modified Benefit Formula Questionnaire

OMB No. 0960-0395

Revisions to the Collection Instrument

SSA is making the following revisions:

• Change #1: SSA is removing the signature requirement from Form SSA-150.

Justification #1: We reassessed the need for a wet signature on this form and determined we no longer require it. Therefore, we will no longer ask respondents to sign this form prior to submitting it to SSA.

Currently, the paper and PDF versions of this form includes a signature requirement. SSA recently reassessed the need for the respondent’s signature on this form and determined that we no longer require it. Therefore, we are removing the signature requirement from this form.

• Change #2:  We are replacing the Penalty of Perjury Statement with a Penalty of Perjury Warning:

Anyone who knowingly 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, or submits or causes to be submitted any false statement or document knowing the same to contain any misrepresentation of material fact, commits a crime punishable under Federal law by fine, imprisonment, or both, and may be subject to administrative sanctions.

Justification #2:  The Penalty of Perjury Statement is directly connected to the signature and needs to be removed since a signature is no longer required. However, to maintain the intent of that statement, we are replacing it with a Penalty of Perjury Warning.

• Change #3: We are revising the PRA statement on this form.

Justification #3: 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  The current language, which dates back to the last reprint of the form, is now outdated.

• Change #4: We are revising the Privacy Act Statement on this form.

Justification #4: 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.

Upon OMB’s approval, we will implement the changes to the form.