Document
Addendum To Supporting Statement
ICR 200702-0960-002 · OMB 0960-0578 · Object 3541201.
ADDENDUM TO SUPPORTING STATEMENT
Revision to the Collection Instrument
SSA needs to revise Section 3 (the bottom part) on page 8 (last page of SSA-3369) to eliminate collecting duplicate information. In most cases, the applicant completing the form is the disabled individual. Since the form is printed every 6 months, SSA will continue to use the current SSA-3369 until stock is depleted.
SSA-3369 – Current page 8
Name of person completing this form (Please print)
|
Date (Month, day year) |
Address (Number and Street)
|
Email address (optional) |
City
|
S |
tate
Zip
CodeForm SSA-3369-BK (1-2005) ef (01-2006) PAGE 8
SSA-3369 – Revised page 8
N
|
E-Mail Address of person completing this form (optional)
|
If the person completing this form is other than the disabled person, please complete the following information. |
R
|
A
|
ame
of person completing this form (Please
print)
Date Form
Completed (Month,
day, year)
elationship
to Disabled Person
Daytime
Telephone Number
| File Type | application/msword |
| File Title | ADDENDUM TO SUPPORTING STATEMENT |
| Author | Kathy |
| Last Modified By | Kathy |
| File Modified | 2007-02-13 |
| File Created | 2007-02-13 |