TN 18 (12-11)
GN 00304.090 Form Letter SSA-L4159 for Law Enforcement Authority
A. Policy for form letter SSA-L4159
You may use a statement from a law enforcement official to document the noninvolvement of a claimant in a homicide.
The statement may be a report of contact or a letter and may be in the law enforcement official's own words or composed by the field office (FO).
To view the SSA-L4159, see OS 15010.747˙.
B. Procedure for completing form letter SSA-L4159
1. Preparing the SSA-L4159
To prepare and forward the form letter
Enter the originating office's address and telephone number in the upper right hand corner;
Enter the name and address of the law enforcement agency or official in the normal letterhead address space;
Enter the name of the deceased, the date and place of death, the decedent's Social Security number and the claimant's name in the space provided; and
Sign the name of the originating claims representative.
2. Mailing form letter SSA-L4159
Take the following actions to mail the form letter SSA-L4159:
Complete identifying information on the form and send it by SSA-562 U3 (Request for Assistance/Certification of Document(s) or Record(s)) to the parallel FO if the law enforcement official is outside the service area; and
Mail the form in a window envelope directly to the law enforcement official. Enclose a postage-paid self-addressed return envelope.