Social Security Administration
Security Claim Number:
On (1) , we talked with (2) about (3) possible entitlement to Social Security benefits. We filled out the enclosed application
for social security benefits based on (4) statements. However, we cannot decide if (5) entitled to benefits until you sign the application and give us more information.
What You Need To Do
Answer any questions circled on the application
Correct any information that is wrong and sign your initials next to the corrections
Sign and date the application and any accompanying forms in the space called, “Your
Mail the application, any accompanying forms and the information or evidence checked
below to the Social Security office address shown above. A self-addressed envelope
is enclosed for your convenience. Add your return address on the envelope and remember
to place the correct amount of postage on it.
If We Do Not Hear From You
It is important that you sign the application and return it to us within 10 days of the date of this notice. The sooner we get the signed application, the sooner we can decide if (6 ) eligible.
IF WE RECEIVE THE SIGNED APPLICATION AFTER ANY OF THE DATES SHOWN BELOW, YOU MAY LOSE
BENEFITS. The block checked below applies to you.
__If we receive the signed application by _____(7)_______, we will use the date we
talked to you about possible entitlement to benefits, ______(8)___________, as the
__If we receive the signed application after ____(9)________, but no later than ___________(10)____________,
we will use the date of the application interview, _________(11)_________, as the
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Things We Need
We need the items checked below. You must send us the original documents except as
noted below. If you do not have the original, you must send a copy certified by the
person who is the custodian of the original record. Do not send copies signed by a
notary public. We will return the item(s) to you. We can accept a photocopy of a W-2
form or a tax return (1040, Schedule C, Schedule SE, etc.). Do not delay signing and
sending us the enclosed application even if you do not have the records we need.
[ ] Birth Certificate or religious record of age (1)______________
[ ] Marriage Certificate (2)_________________________
[ ] Divorce or Annulment Decree (3)_________________________
[ ] U.S. Passport, Certificate of Citizenship or Naturalization, or current immigration
[ ] Withholding statement (Form W-2) for (5)_________________
[ ] Tax return and Schedule SE for ___(6)___________________
[ ] Certificate of Appointment as legal representative for _(7)______
[ ] Death Certificate for (8)________________________________
[ ] Award letter or correspondence concerning (9)______________
[ ] Military service discharge papers (10)______________
[ ] Blank check for direct deposit information (write “VOID” on the front of the check)
[ ] (12) _______________________________________________________
If You Have Any Questions
If you have any questions, you should call, write or visit any Social Security office.
If you call or visit our office, please have this letter with you and ask for (12).
The telephone number is shown above. 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.
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