BASIC (03-04)

GN 01085.025 Exhibit - Retention Periods For Program-Related Forms

Exhibit

The following exhibit is to be used as a guide for discarding forms in a claims folder. Although many forms are displayed, this is not an all-inclusive list. Additional forms and any changes to current retention periods will be added in future updates. The retention information was extracted from pertinent sections of the Administrative Instructions Manual System (AIMS), the Materiel Resources Manual - Chapter 07, and the Records Management Handbook, and from a policy review of the program-related forms currently mentioned in certain sections of the POMS. The exhibit provides form numbers in numerical order with titles and retention periods. Note that, unless otherwise annotated, all forms with a multiple suffix (e.g., F6, SP, U2, etc.) have the same retention disposition as the basic numeric form.

FORM NUMBER

 TITLE

RETENTION DISPOSITION

SSA-1

Application for Retirement
Benefits

UNTIL paper claims file is destroyed.

SSA-2-F6

Application for Spouse Insurance Benefits

UNTIL paper claims file is destroyed.

SSA-3

Marriage Certification

UNTIL paper claims file is destroyed.

SSA-4-BK

Application for Child Insurance Benefits

UNTIL paper claims file is destroyed.

SSA-5-F6

Application for Mother or Father Insurance Benefits

UNTIL paper claims file is destroyed.

SSA-7-F6

Application for Parent Insurance Benefits

UNTIL paper claims file is destroyed.

SSA-8-F4

Application for Lump Sum Death Payment

PAPERLESS LSDP ONLY CLAIMS
Destroy 60 DAYS after verification of systems acceptance of LSDP action. ALL OTHER LSDP / SURVIVOR CLAIMS
UNTIL paper claims file is destroyed.

SSA-10-BK

Application for Widow(er)
Insurance Benefits

UNTIL paper claims file is destroyed.

SSA-11-BK

Request to be Selected as Payee

UNTIL paper claims file is destroyed.

SSA-16-F6

Application for Disability
Insurance Benefits

UNTIL paper claims file is destroyed.

SSA-19-F6

Application for Special Age 72-or-Over Monthly Payments

UNTIL paper claims file is destroyed.

SSA-21

Supplement of Claim of Person Outside the U.S.

UNTIL paper claims file is destroyed.

VA-21-4182

Abbreviated Application for VA Benefits

Do NOT retain unless used for protective filing; then retain UNTIL paper claims file is destroyed.

VA-21-8046

VA Payment Notice (Stop-Suspend-Resume)

Do NOT retain.

SSA-24

Application for Survivor Benefits

UNTIL paper claims file is destroyed.

SSA-25

Certificate of Election for Reduced Spouse Benefits

UNTIL paper claims file is destroyed.

BRI-46-289

Inquiry from OPM

Do NOT retain.

VA-70-7210

Request for Index and Locator Information

Do NOT retain.

SSA-101-U3

Determination of Award -
Manual

UNTIL paper claims file is destroyed.

SSA-L106

School Certification of Birth Data

Destroy 120 DAYS after receipt and verification of systems acceptance or the discrepancy is closed.

SSA-122

Request for Additional Information

Do NOT retain.

SSA-149

Waiver of Benefit Payments.

UNTIL paper claims file is destroyed.

SSA-150

Modified Benefit Formula Questionnaire for the Windfall Elimination Provision (WEP)

UNTIL paper claims file is destroyed.

SSA-174

Representative Payee Diary Card

Do NOT retain.

SF-180

Request Pertaining to Military Service Records

Do NOT retain.

SSA-208

Authorization for Garnishment

UNTIL paper claims file is destroyed.

SSA-209

Garnishment Information
Update

UNTIL paper claims file is destroyed.

DD-214

Statement of Military Service

UNTIL paper claims file is destroyed.

SSA-L244

Letter Transmitting Reconsideration Determination

Destroy 120 DAYS after verification of systems acceptance of the reconsideration decision.

SSA-250

Development Worksheet

Destroy 120 DAYS after completion of development.

SSA-L250

Notice of Application for Withdrawal of Claim

UNTIL paper claims file is destroyed.

SSA-L293-U2

RSDI Notice of Unscheduled CDR

Do NOT retain.

SSA-381-SP

Waiver of Option to Receive Spanish Language Notice

UNTIL paper claims file is destroyed.

SSA-385

OIO Case Folder Flag

Destroy when case is returned to OIO.

SSA-408

Route Slip

Do NOT retain.

SSA-409

Postadjudicative Routing

Do NOT retain.

SSA-450

Claims Input Data Form

Destroy 30 DAYS after verification of systems acceptance.

SSA-454-BK

Report of Continuing Disability Interview

UNTIL paper claims file is destroyed.

SSA-455

Disability Update Report

UNTIL paper claims file is destroyed.

SSA-492

PC Case Folder Flag

Destroy when claim is returned to appropriate PC.

HA-520-U5

Request for Review of Hearing Decision/Order

Destroy 120 DAYS after final ODAR decision.

SSA-521

Request for Withdrawal of
Application

UNTIL paper claims file is destroyed.

SSA-533

Translation Request

UNTIL paper claims file is destroyed.

HA-539

Notice Regarding Substitution of Party (Upon Death of Claimant)

Destroy 120 DAYS after death of claimant.

SSA-546

Workers' Compensation/Public Disability Benefits Information

UNTIL paper claims file is destroyed.

SSA-553

Special Determination

UNTIL paper claims file is destroyed.

SSA-559

Transmittal Sheet for Claims Folder/Material

Do NOT retain unless used for adjudication; then retain UNTIL paper claims file is destroyed.

SSA-561-U2

Request for Reconsideration

UNTIL paper claims file is destroyed.

SSA-562-U3

Request for Assistance/
Certification of Documents or Records

UNTIL paper claims file is destroyed.

SSA-L566

SSA Application Development

Destroy 120 DAYS after receipt and verification of systems acceptance or the discrepancy is closed.

SSA-573

Special Typing Instructions

Do NOT retain unless language is unavailable elsewhere; then retain UNTIL paper claims file is destroyed.

SSA-622-SM

Representative Payee Questionnaire –Individual

Destroy 30 DAYS after verification of systems acceptance.

SSA-623-F6

Representative Payee Report

UNTIL paper claims file is destroyed.

SSA-623-OCR-SM

Representative Payee Report

Destroy 30 DAYS after verification of systems acceptance.

SSA-624-F5

Representative Payee Evaluation Report

UNTIL paper claims file is destroyed.

SSA-625

Report by Former Representative Payee

UNTIL paper claims file is destroyed.

SSA-632-BK

Request for Waiver of Overpayment Recovery or Change in Repayment Rate

UNTIL paper claims file is destroyed.

SSA-632-SUP

Recovery Interview Supplement

UNTIL paper claims file is destroyed.

SSA-635

Waiver Determination

UNTIL paper claims file is destroyed.

SSA-636-U3

Transmittal Notice for a Hearing

Do NOT retain.

SSA-654-U4

Request for Information From Uniformed Services

UNTIL paper claims file is destroyed.

SSA-655-U2

Certification by Federal Agency

UNTIL paper claims file is destroyed.

SSA-656

Information as to Continuing Eligibility Under Title 38 USC, Section 412, Veterans' Benefits

UNTIL paper claims file is destroyed.

SSA-662

Reconsideration Determination

UNTIL paper claims file is destroyed.

SSA-702

Statement Regarding Date of Birth and Citizenship

UNTIL paper claims file is destroyed.

SSA-704

Certification of Contents of Document(s) or Record(s)

Destroy 120 DAYS after receipt and verification of systems acceptance or the discrepancy is closed.

SSA-L706

Proof of Age Letter to Custodian

Destroy 120 DAYS after receipt and verification of systems acceptance or the discrepancy is closed.

SSA-721

Statement of Death By Funeral Director

PAPERLESS LSDP ONLY CLAIMS
Do NOT retain. ALL OTHER LSDP /
SURVIVOR CLAIMS
UNTIL paper claims file is destroyed.

SSA-723-F4

Statement Regarding Presumed Death Due to Unexplained Absence

UNTIL paper claims file is destroyed.

SSA-L725

Employer Verification of Monthly Wages (see OS 15010.347)

UNTIL paper claims file is destroyed.

SSA-730-U2

Request to Have SSI Overpayment Withheld From SSA Benefits

UNTIL paper claims file is destroyed.

SSA-L732

Additional Information Needed From Claimant to Adjudicate Claim

Do not retain after receipt and verification of systems acceptance or the discrepancy is closed.

SSA-753

Statement Regarding Marriage

UNTIL paper claims file is destroyed.

SSA-754-F4

Statement of Marital Relations

UNTIL paper claims file is destroyed.

SSA-760-F4

Certificate of Support

UNTIL paper claims file is destroyed.

SSA-766

Statement of Self-Employment

Destroy 1 YEAR after verification of earnings record update or the discrepancy is closed.

SSA-768

Certification of Evidence of Wages

Destroy 120 DAYS after verification of earnings record update or the discrepancy is closed.

SSA-781

Certificate of Care and Responsibility for Welfare of Child Not In Applicants Custody

UNTIL paper claims file is destroyed.

SSA-783

Statement Regarding Contributions

UNTIL paper claims file is destroyed.

SSA-787

Physician/Medical Officer Statement

UNTIL paper claims file is destroyed.

SSA-788

Statement of Care and Responsibility for Beneficiary

UNTIL paper claims file is destroyed.

SSA-790-RR

Request for Railroad Earnings

UNTIL paper claims file is destroyed.

SSA-795

Statement of Claimant or Other Person

UNTIL paper claims file is destroyed.

SSA-827

Authorization to Release Medical Information to SSA

UNTIL paper claims file is destroyed.

SSA-828-U4

Request for Medical Information from VA

Do NOT retain.

SSA-829-U4

Request for Medical Information From Military Facilities or Records Center

Do NOT retain.

SSA-831-U3

DIB Determination and Transmittal Sheet

UNTIL paper claim or postentitlement file is destroyed.

SSA-832-U3

Cessation or Continuance of Disability/Blindness Determination and Transmittal - Title XVI

UNTIL paper claim or postentitlement file is destroyed.

SSA-833-U3

Cessation or Continuance of Disability/Blindness Determination and Transmittal - Title II

UNTIL paper claims file is destroyed.

SSA-892-U2

ESRD Medical Determination

UNTIL paper claims file is destroyed.

SSA-924

Folder Documentation

UNTIL paper claims file is destroyed.

SSA-1002-F3

Statement of Agricultural Employer for Years Before 1988

Destroy 120 DAYS after verification of earnings record update or the discrepancy is closed.

SSA-1003-F3

Statement of Agricultural Employer for Years After 1987

Destroy 120 DAYS after verification of earnings record update or the discrepancy is closed.

SSA-1099-SM

SS Benefit Statement

Do NOT retain.

SSA-1129-U3

Attorney Fee Case Past-Due Benefit Summary

UNTIL paper claims file is destroyed.

SSA-L1157-U2

Notice of Disability

Destroy 120 DAYS after date of the notice.

SSA-1178

Evaluation of Fee Petition

UNTIL paper claims file is destroyed.

SSA-1203

Determination of Benefits Payable After Offset (WC/PDB)

UNTIL paper claims file is destroyed.

SSA-1208

Keep Flag on Top

Destroy 30 DAYS after verification of systems acceptance or the discrepancy is closed.

DD-1300

Report of Casualty

UNTIL paper claims file is destroyed.

SSA-1314

Annual Report Data

Destroy 30 DAYS after verification of systems acceptance.

SSA-1323

Report On Individual With Childhood Impairment

UNTIL paper claims file is destroyed.

SSA-1372

Student's Statement Regarding School Attendance

UNTIL paper claims file is destroyed.

SSA-1383

Student Reporting Form – Changes

Destroy 30 DAYS after verification of systems acceptance.

SSA-1386-U2

Student's Statement Regarding Resumption of School Attendance

Destroy 120 DAYS after receipt and verification of systems acceptance.

SSA-1388-U2

Report of Student Beneficiary at End of School Year

Destroy 120 DAYS after receipt and verification of systems acceptance.

SSA-1390

Report of Student Beneficiary About to Attain Age 19

Destroy 120 DAYS after receipt and verification of systems acceptance.

SSA-1425

Reporting Changes That Affect SSA Payment

Destroy 30 DAYS after verification of systems acceptance.

SSA-1473

Request for Railroad Annuity Information

UNTIL paper claims file is destroyed.

SSA-1535-U3

Application for Search of Census Records

UNTIL receipt of requested evidence.

SSA-1588-OCR-SM

Beneficiary Recontact Report

Do NOT retain.

SSA-1671-U2

Transmittal of Critical Case

Do NOT retain.

SSA-1696-U4

Appointment of Representative

UNTIL paper claims file is destroyed.

SSA-1709

Request for Workers' Compensation/Public Disability Benefits Information

UNTIL paper claims file is destroyed.

SSA-1719

RSI Postentitlement Direct Input

Destroy 30 DAYS after verification of systems acceptance.

SSA-1719-B

SSI Postentitlement Direct Input

Destroy 30 DAYS after verification of systems acceptance.

SSA-1719-C

SSI Postentitlement Direct Input

Destroy 30 DAYS after verification of systems acceptance.

SSA-1719-NC

SSI Non-receipt Direct Input

Destroy 30 DAYS after verification of systems acceptance.

SSA-1720

Annual Report Direct Input

Destroy 30 DAYS after verification of systems acceptance.

SSA-1724

Claim for Amounts Due

UNTIL paper claims file is destroyed.

SSA-1826

Sample Itemized Statement of Earnings

Destroy 120 DAYS after earnings record update or the discrepancy is closed.

PHS-1867

Public Health Service DMW Credit Reporting Form

UNTIL paper claims file is destroyed.

SSA-2118-U2

Request for Document or
Information

Destroy 120 DAYS after verification of systems acceptance or the discrepancy is closed.

SSA-2164

Work Notice Direct Input

Destroy 30 DAYS after verification of systems acceptance.

SSA-2417-C1

Determination of Benefit Rights

UNTIL paper claims file is destroyed.

SSA-2454

Offset Worksheet (WC/PDB) –
Triennial Redetermination
Previously Applied

UNTIL paper claims file is destroyed.

SSA-2455

WC/PDB Offset Worksheet –
Disability

UNTIL paper claims file is destroyed.

SSA-2506-BK

Psychiatric Review Techniques

UNTIL paper claims file is destroyed.

SSA-2512

Pre-1957 Military Service-Federal Benefit Questionnaire

UNTIL paper claims file is destroyed.

SSA-2514

Claimant's Intent to File

UNTIL paper claims file is destroyed.

SSA-2519

Child Relationship Statement

UNTIL paper claims file is destroyed.

SSA-2521

Request for Priority Action

Do NOT retain.

SSA-2708

Request to Call or Visit the District Office

Do NOT retain.

SSA-2764

SALT Coding Sheet

Destroy 30 DAYS after verification of systems acceptance.

SSA-2795-U2

Determination of Resumption of Award

UNTIL paper claims file is destroyed.

SSA-L3044-C1

Social Security Notice to Employee

Do NOT retain.

SSA-3105

Important Information About Your Review Rights

UNTIL paper claims file is destroyed.

SSA-3368-BK

Disability Report

UNTIL paper claims file is destroyed.

SSA-3369-BK

Work History Report

UNTIL paper claims file is destroyed.

SSA-L3400-C1

Social Security Notice

Do NOT retain.

SSA-3428-U2

Determination of Disallowance

UNTIL paper claims file is destroyed.

SSA-3440-EP

Claims Collection Litigation Report

UNTIL paper claims file is destroyed.

SSA-3441-BK

Reconsideration Disability
Report

UNTIL paper claims file is destroyed.

SSA-3601

MCS or Non-CAPS Routing Form

Do NOT retain.

SSA-3621

MBR Account/Benefit Data Change Form

Destroy 30 DAYS after verification of systems acceptance.

SSA-3643

Offset Worksheet (WC/PDB) – Triennial Redetermination

UNTIL paper claims file is destroyed.

SSA-3820-F6

Medical History and Disability Report

UNTIL paper claims file is destroyed.

SSA-3826-F4

Medical Report

UNTIL paper claims file is destroyed.

SSA-3827

Medical Report (Individual With Childhood Impairment)

UNTIL paper claims file is destroyed.

SSA-3881-BK

Questionnaire For Children Claiming SSI Benefits

UNTIL paper claims file is destroyed.

SSA-3885

Government Pension Questionnaire

UNTIL paper claims file is destroyed.

SSA-3926

Determination of Benefit
Adjustment

UNTIL paper claims file is destroyed.

SSA-4078

Request for Earnings After Death

Do NOT retain.

SSA-L4107

Change of Address – Additional Information Needed

Do NOT retain.

SSA-4111

Certificate of Election for
Reduced Widow(er) Benefit

UNTIL paper claims file is destroyed.

SSA-L4112-C1

Request for Employment Information

UNTIL paper claims file is destroyed.

SSA-L4157

Request for Earnings Information

Do NOT retain.

SSA-4162

Child-Care Dropout Questionnaire

UNTIL paper claims file is destroyed.

SSA-4164

Consent Form for a Representative Payee

UNTIL paper claims file is destroyed.

SSA-4184

Self-Employment/Corporate
Officer Questionnaire

UNTIL paper claims file is destroyed.

SSA-4268-U4

Explanation of Determination

UNTIL paper claims file is destroyed.

SSA-4345

SSI Offset Worksheet Federal

UNTIL paper claims file is destroyed.

SSA-L4360-SP

SS Benefit Information

UNTIL paper claims file is destroyed.

SSA-4385

Certification of Contents of Court Records

GENERAL USE
Destroy 120 DAYS after receipt and verification of systems acceptance or the discrepancy is closed. REP PAYEE GUARDIAN /
CAPABILITY ISSUES AND PRISONER CASES
UNTIL paper claims file is destroyed.

SSA-4500-U6

Federal Determination of Error in State's Wage Reports

Destroy 120 DAYS after verification of earnings record update.

SSA-4582-CD

Wage Suspense/Reinstate Card

Destroy 120 DAYS after verification of earnings record update.

SSA-4641-U2

Authorization for SSA to Obtain Personal Information

UNTIL paper claims file is destroyed.

SSA-4734-U8

Residual Physical Functional Capacity Assessment

UNTIL paper claims file is destroyed.

SSA-4734-F4-SUP

Mental Residual Functional Capacity Assessment

UNTIL paper claims file is destroyed.

SSA-5002

Report of Contact

UNTIL paper claims file is destroyed.

SSA-L5004

Acknowledgment of Misdirected Tax

Do NOT retain.

SSA-5015-U2

Diary and Listing Slip

Destroy after issue is resolved or followup diary prepared.

SSA-5016

Scouting Request – Pending Claim

UNTIL paper claims file is destroyed.

HA-5051-U3

Transmittal of ALJ's Decision or Dismissal to ODAR

Destroy 120 DAYS after verification of systems acceptance of decision.

SSA-5052

RSI Health Insurance Information Request

UNTIL paper claims file is destroyed.

SSA-L5114

Letter Notifying Self-Employed Claimant of Adjustment

UNTIL paper claims file is destroyed.

SSA-5526 U3

Request for Assistance – Disability

Destroy 120 DAYS after verification of systems acceptance or the discrepancy is closed.

SSA-5527-U3

Request for Assistance – Representative Payee

Destroy 120 DAYS after verification of systems acceptance or the discrepancy is closed.

SSA-6220-SM

Representative Payee Questionnaire -Institutions

Destroy 30 DAYS after verification of systems acceptance.

SSA-6230-F6

Representative Payee Report for Children

UNTIL paper claims file is destroyed.

SSA-6230-OCR-SM

Representative Payee Report for Children

Destroy 30 DAYS after verification of systems acceptance.

SSA-7000-U5

Notice of Determination of Self-Employment Income

UNTIL paper claims file is destroyed.

SSA-7004-SM

Request for Earnings and Benefit Estimate Statement

Do NOT retain unless used for protective filing; then retain UNTIL paper claims file is destroyed.

SSA-7005

Personal Earnings and Benefit Estimate Statement (PEBES)

Do NOT retain unless used for protective filing; then retain UNTIL paper claims file is destroyed.

SSA-7008

Request for Correction of
Earnings

Destroy 4 YEARS after determination is made or the discrepancy is closed.

SSA-7010-U5

Notice of Determination of FICA Wages

Destroy 120 DAYS after verification of earnings record update.

SSA-7011-F4

Statement of Employer Regarding Earnings

Destroy 120 DAYS after verification of earnings record update or the discrepancy is closed.

SSA-L7013

Request to Employer for Wage Information

Destroy 120 DAYS after verification of earning record update or the discrepancy is closed.

SSA-L7014

Request for Earnings Information

Destroy 120 DAYS after verification of earnings record update or the discrepancy is closed.

SSA-L7015

Follow Up to SSA-L7014
Request

Do NOT retain.

SSA-7052

DO Record of Earnings Discrepancy Development

Destroy 120 DAYS after verification of earnings record update or the discrepancy is closed.

SSA-7057-U3

Request for Tax Return Information

UNTIL paper claims file is destroyed.

SSA-7104

Partnership Questionnaire

UNTIL paper claims file is destroyed.

SSA-7157-F4

Farm Arrangement Questionnaire

UNTIL paper claims file is destroyed.

SSA-7160

Employment Relationship Questionnaire

UNTIL paper claims file is destroyed.

SSA-7161

Foreign Enforcement Questionnaire

UNTIL paper claims file is destroyed.

SSA-7162

Foreign Enforcement Questionnaire

UNTIL paper claims file is destroyed.

SSA-7163

Questionnaire About Employment or Self-Employment
Outside USA

UNTIL paper claims file is destroyed.

SSA-7774-SM

Underpayment Detection
Annual Report

Destroy 30 DAYS after verification of systems acceptance.

SSA-8000-BK

Application for SSI - Long Form

UNTIL paper claims file is destroyed.

SSA-8001-F5

Application for SSI - Short Form

UNTIL paper claims file is destroyed.

SSA-8006-F4

Statement of Living Arrangements, In-Kind Support and Maintenance

UNTIL paper claim or postentitlement file is destroyed.

SSA-8008

Living Arrangement and In-Kind Support and Maintenance Guide

UNTIL paper claim or postentitlement file is destroyed.

SSA-8010-BK

Statement of Income and Resources

UNTIL paper claim or postentitlement file is destroyed.

SSA-8011-F3

Statement of Household Expenses and Contributions

UNTIL paper claim or postentitlement file is destroyed.

SSA-8202-F6

Statement for Determining Continuing Eligibility for SSI Payment

Destroy 7 YEARS after completion of the redetermination action.

SSA-8203-BK

Statement for Determining Continuing Eligibility for SSI Payment

UNTIL paper claim or postentitlement file is destroyed.

SSA-8299

Request for Special Age 72 Reinstatement

UNTIL paper claims file is destroyed.

SSA-8510

Authorization to SSA to Obtain Personal Information

UNTIL paper claims file is destroyed.

SSA-8740

Referral and Treatment Status of SSI Drug Addicts and Alcoholics

UNTIL paper claim or postentitlement file is destroyed.

SSA-9432

Notice Regarding Military Service Wage Credits

Do NOT retain.

SSA-9584-BK

State Mental Institution Policy

UNTIL paper claims file is destroyed.

SSA-9584-SUP

Certification by State Mental Institution

UNTIL paper claims file is destroyed.

SSA-L9778-SM

Work Report

Destroy 30 DAYS after verification of systems acceptance.

SSA-L9779-SM

Work Report

Destroy 30 DAYS after verification of systems acceptance.

SSA-L9780-SM

Work Report

Destroy 30 DAYS after verification of systems acceptance.

SSA-L9781-EP

Work Report

Destroy 30 DAYS after verification of systems acceptance.

NA-13041

Statement of Service

UNTIL paper claims file is destroyed.

NA-13047

Reply to Request for Information

Do NOT retain.

NA-13075

Questionnaire About Military Service

Do NOT retain.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0201085025
GN 01085.025 - Exhibit - Retention Periods For Program-Related Forms - 01/02/2015
Batch run: 01/02/2015
Rev:01/02/2015