The SSA-8202-F4-INST is enclosed with mail out SSA-8202-BK RZs.

The SSA-8202-F4-INST is a 4-page form folded to 3-3/4" 8-1/2". There are four versions of the form:

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  SSA-8202-F4-INST and SSA-8202-F4-SP-INST are the English and Spanish versions of the forms for use by all States except California. These versions include a food stamp message.

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  SSA-8202-F4-INST-NFS and SSA-8202-F4- INST-SP-NFS are the English and Spanish versions of the forms for use by California only. These versions do not include a food stamp message.

All versions of the form include information about:

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  Why we conduct RZs;

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  How to complete the SSA-8202-BK;

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  Timeframe for responding and the consequences of not responding;

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  Recipient reporting responsibilities;

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  Computer matching;

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  Food stamps (in all States but California);

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  Medicaid transfer of assets;

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  Paperwork Reduction Act of 1995; and

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  Privacy Act.

Following is the procedure for use of the SSA-8202-F4-INST:

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  Put the month/day/year you are mailing the form in the DATE block of two copies of the SSA-8202-F4-INST.

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  Enclose a copy with the form SSA-8202-BK you are mailing to the recipient.

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  Retain the other copy in the file to document the 30-day timeframe for close-out purposes.

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  SI 02305.804 SSA-8202-F4-INST, Important Facts About Your Supplemental Security Income (FO, Food Stamp Version)