Addendum to Supporting Statement

Addendum to the Supporting Statement for Form SSA-1709

Request for Workers’ Compensation/Public Disability Benefit Information

20 CFR 404.408(e)

OMB No. 0960-0098

Revision to the Collection Instrument

We are making minor changes to the form.

Change 1: - We are revising question number 6.

• Old Language: “DATE IF INJURY OR ONSET OF DISEASE (if applicable)”

• New Language: “DATE OF INJURY OR ONSET OF DISEASE (if applicable)”

Justification 1:

We are correcting a typing error.