Social Security Administration
Regional Office- __________________
Date:

      

   

Special Agent's Name
Special Agent's Title
SSA/OIG
6401 Security Boulevard
Baltimore, MD 21235

   

     

Dear (Agent's Name):

This is in reference to your letter dated ____________, about payments made to ___________(Recipient's Name), Social Security number _____________ for the period _____________ through _______________ . Please see enclosed extract.

     

If you have any further questions regarding this, please contact __________________, Region _____, at _________________ .

    

Sincerely,
(Name)____________
(Title)____________
Regional Office ____________

 

Enclosure

   

Office of the Inspector General
Office of Investigations
Social Security Administration

   

     

Date:         _______

To:         Social Security Administration (Regional Offices addresses)
Fax:

   

     

From:        _______________________________________

                  _______________________________________

   

       

Subject:      Request for: ­­­­­­­­­­­­­­­­­­­­__________________________________________________

RE:            SSA OIG OI File Number (SSN) ________________________________

   

In conjunction with an official investigation being conducted by this office, this is a request for (if requesting payment extract, provide period of time covered):
_________________________
_________________________
_________________________

Please forward the documents identified above to _______________________ at the following address no later than ___________

                     ­­­­­­­­­­­­_________________________________________________

                     ­­­­­­­­­­­­_________________________________________________

                     ­­­­­­­­­­­­_________________________________________________

                     ­­­­­­­­­­­­_________________________________________________

                     ­­­­­­­­­­­­_________________________________________________

                     (Requester phone number: _____________________) 

Request of Title II (SSA) Benefit Payments

   

Send to:

Social Security Administration

Center for Security and Integrity

(Insert the Processing Center of jurisdiction address )

   

Requests involving all Foreign Claims and Disability Claims under Age 55        

Please prepare:

of benefits for all payments issued to the following beneficiary (ies) under the following Social Security number(s) during the listed period:

    

Social Security Number (SSN):                          

Time Period for record of payments (only months/years involved in investigation)

 

This request is part of an investigation of a possible fraud/violation of the _______________________________________________ program(s).
Case Number: _______________
Name of Requester: _______________
Title of Requester:  _______________ 
Office of Requester: _______________         

Requester Phone NO: _______________                   

Date:  _____________              Signature _____________    

 

 

Letterhead Memorandum Paper

    

 (Claimant's name), Request for Certified Extract (Request dated ______) (Include reference number in the subject line)          

  

Attached are the authorization for certification of extract records, certified extract of benefits for payments issued to all beneficiaries on this account from _________through__________.

    

Payments certified for the period______through______were for payment via direct deposit to (Bank’s name and address), for deposit to checking/savings account number ______and identified by the routing and transit number
(RTN)                                                    .

  (Complete only if applicable)   

                
(Director's Signature)
  

                
(Director’s Name)

 

 

Process Division__________
Attachments

   

     

Baltimore, Maryland 21241
Refer to:              

 (Requesting office Name and Address)

    

CERTIFICATION OF EXTRACT FROM RECORDS

In accordance with provisions of Title 42, United States Code (USC), Section 904, and the authority vested in me by 42 U.S.C. 902, I hereby certify that I have legal custody of certain records, documents, other information established and maintained by the Social Security Administration, pursuant to Title 42, United States Code, Section 405, and that the annexed is a true extract from such records in my custody as aforesaid.

I further certify that all signatures of the Social Security Administration officials on the annexed document(s) are genuine and made in accordance with the signers’ official capacity

IN WITNESS WHEREOF, I have set my hand and caused the seal of the Social Security Administration to be affixed this ________day of_______.

     

     

          
(Director's Signature)
            
(Director's Name)

 

        

     

Social Security Administration
Refer to: ________

            

To Whom It May Concern:

           

The following Social Security benefits in the chart below were certified for payment to John Doe and Jane I. Doe under Social Security claim number 000-00-0000 for the period July 3, 1997 through June 3, 1998 and have not been reported as non-receipt items.

     

   

Social Security Administration
Request for Title XVI Payment Extract

   

To: Social Security Administration (Regional Offices addresses)
Fax:

   

From:

  

Subject: Request for: (check one)

   

 ____(a) Certified extract (court date scheduled for) ______ or  ______ (b) Extract (no court date scheduled) of benefits for all payments issued to (Recipient's Name)_____________ , (Payee's Name, if appropriate)____________ , (Recipient's SSN)     ______________ for the period of ________ through (use MM/YY format).

    

Please forward the materials requested to the following name and address
by__________________.

                                                                    

_______________________________

 

Phone:   ___________________             

 Requester's Signature: _________________                  Date: _______________

    

Thank you for your assistance in this matter.

   

Social Security Administration
Regional Office ______________

   

I, _________________________, Social Security Administration, Region ___, hereby certify that the following business system records of the Social Security Administration pertain to the record of (Recipient's Name ) ________________ , Social Security number _________________ .

I further certify that the records of the Social Security Administration show that eligibility for the Supplemental Security Income (SSI) payments as of (Date)____________ , under Section 1602 of the Social Security Act were paid to (Recipient's Name) __________________ .

   

Below is the record of the SSI payment(s) for the period you requested. I further certify that the current representative payee is (Representative Payee's Name, when appropriate) ___________________.

   

   

Sincerely,
  
(Name) 
   
(Title) 
   
 Regional Office _____________________