Social Security Administration
Supplemental Security Income
On (1) , we talked with you and completed an application for (2) . We stored the application information electronically in our records and are enclosing
a summary of your statements.
What You Need to Do
Review the application information to ensure we recorded your statements correctly.
If you agree with all your statements, you may retain the information for your records.
If you disagree with any of your statements, you should contact us within 10 days
after the date of this notice to let us know.
Penalty of Perjury
You declared under penalty of perjury that you examined all the information on this
form and it is true and correct to the best of your knowledge. You were told that
you could be liable under law for providing false information.
What We Need (optional paragraph)
We need the items listed below to decide if ___ (3) _______ can receive benefits.
We must see the original document(s) or a certified copy of the item(s). We cannot
accept photocopies except for tax returns. We will return the item(s) to you.
Please bring or mail these items to us right away. The sooner we receive the item(s),
the sooner we can decide if ___ (4) _______ eligible.
APT040 Proof of age
APT041 Proof of marriage
APT042 Proof of divorce or annulment
APT012 Proof of death
APT015 Proof of tax/wage withholding
APT020 Proof of income
APT021 Proof of resources
APT097 Evidence—citizenship/residence status
APT010 Proof needed with disability claim
DID024 Bank name, account number, and routing number for direct deposit
INF011 Request for life insurance policies
INF006 Request for pension records
INF007 Request for pay stubs
INF008 Request for self-employment records
INF009 Request for unemployment compensation records
INF010 Request for workers' compensation award letter
INF025 SSA-827 Authorization
If We Do Not Hear From You (SSI only paragraph and required if evidence paragraph
If you do not respond to our request for information or evidence or contact us by
(5) , we may deny your application for SSI. Even if you don't have all of the information,
we need to hear from you. We will help you get anything you do not have.
Information about Medicaid (SSI only)
In many States, filing for SSI means you are also filing for Medicaid. If we deny
your SSI application, you cannot get Medicaid based on SSI.
If You Have Any Questions
If you have any questions, you may call, write or visit any Social Security office.
If you call or visit, please have this letter with you and ask for (6) . The telephone number is (7) . We can answer most questions over the phone.
Also, if you plan to visit an office, you may call ahead to make an appointment. This
will help us serve you more quickly.
Application or summary
Form(s) (8) __
Date of Interview (mm/dd/yyyy)
Choice 1 — Supplemental Security Income (SSI)
Choice 2 — Social Security Benefits
Choice 3 — Social Security and SSI
Choice 4 — Medicare only
Enter as appropriate: you, name of claimant
Enter as appropriate: you are, name of claimant is
30 days after the date of the notice (mm/dd/yyyy)
Claims representative’s (CR) name
CR’s telephone number
Form SSA- (Enter the form number(s))
1. Completing the DPS attestation cover notice
After selecting the appropriate Title II or Title XVI header, and English or Spanish
text, complete the DPS attestation cover notice as follows:
a. Identifying information
Enter the proper applicant’s name and address information.
Enter the FO or teleservice center address.
Enter the date you issue the notice.
Enter the claimant’s SSN.
Enter the date of the interview.
Enter the type of claim.
No fill-ins are required for the text under this caption.
This caption is mandatory.
This caption is mandatory.
No fill-ins are required for the text.
g. What we need (optional paragraph for Title II or Title XVI when evidence is being
Select the evidence being requested.
h. If we do not hear from you (SSI only paragraph and required if evidence paragraph
Enter the evidence closeout paragraph which is mandatory for Title XVI when evidence
NOTE: Fill-in (5) __: Enter a date that is 30 days after the date of the notice.
For Title II evidence requests, apply the normal evidence follow-up and closeout procedures
as outlined in GN 00301.150.
i. Information about Medicaid (SSI only)
The language under this caption is mandatory for Title XVI claims.
j. If you have any questions
Fill-in (6) Enter the name of the claims representative (CR) in the space provided.
Fill-in (7) Enter the telephone number of the CR in the space provided.
Type the words “Application or summary as appropriate.”
Fill-in (8) Enter the form number(s) in the space provided.
l. Disposition of the notice
For in-person claims, the attestation cover notice will accompany the application
or summary and/or form(s) that is given to the proper applicant for his or her records,
along with the claim receipt.
For teleclaims, the attestation cover notice will be mailed to the proper applicant
with the application or summary and/or form(s) for his or her retention, along with
the claim receipt.