We are completing our work on your application for Supplemental Security Income (SSI) payments. This letter explains how we plan to pay you if we decide that you can get SSI. We will send you another letter when we make our decision.

 

How We Plan To Pay You

The information we have shows you need help managing your money and meeting your daily needs. Because of this information, we plan to send your SSI payments to (1) . We call this (2) your representative payee.

It is your representative payee's duty to manage your SSI money. The representative payee must report changes that can affect your payments and act in your best interest. We will ask your representative payee to show us how the money was used for you.

 

If You Disagree With The Decision

If you think you should get your own payments or that someone else should help you manage your SSI money, you have the right to appeal. We will review your case and consider any new facts you have. Then, a person who didn't make the first decision will decide your case.

• •

  You have 60 days to ask for an appeal. However, unless we hear from you within 10 days, we will select the representative payee named above.

• •

  The 10 days and 60 days start the day after you receive this letter. We assume you got this letter 5 days after the date on it unless you show us that you did not get it within the 5-day period.

• •

  You must have a good reason for waiting more than 60 days to ask for an appeal.

• •

  You have to ask for an appeal in writing. We will ask you to fill out Form SSA-561-U2 called “Request for Reconsideration.” To get this form, contact one of our offices. We can help you fill out the form.

   

How To Appeal

3769C

 

If You Want Help With Your Appeal

3215E

 

If You Have Any Questions

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  The FO will send this notice to a legally competent SSI recipient. In concurrent cases, separate notices are sent. However, if they are adjudicated simultaneously, a dictated paragraph may be added so that one notice is released. This notice should not be sent until the determination of entitlement is made.

   

Fill-ins:

1. (1) 

   name of representative payee

2. (2) 

   person/organization

    

Paragraph 3763A:

1. (1) 

   FO contact

2. (2) 

   FO contact's telephone number

If an application has been filed by the officer of an institution, or entity, show the title of the officer and the name of the institution or entity. Do not show the name of such officer.

This notice will be sent by the FO. It may be reproduced on FO letterhead.