TN 8 (12-07)

SI 00510.031 Exhibit of the SSA-L8051-U3 (Referral Notice for Social Security Benefits

A. Exhibit of First Page - Claim Information Notice

SOCIAL SECURITY ADMINISTRATION

Supplemental Security Income

Referral Notice for Social Security Benefits

                                                                                         Office Address:

                                                                                                 Office Hours:

                                                                                         Telephone Number:

                                                                                         Date:

                                                                                         Respond by Date:

                                                                                         Claim Number:

This letter is to inform you that you may be eligible to receive Social Security benefits. If you are already receiving Social Security benefits, you may be entitled to an even higher benefit.

We want you to know that an application for Supplemental Security Income (SSI) payments is also an application for Social Security benefits. When SSA determines that a person is eligible to receive SSI payments, he or she is required by law to provide any additional information we ask for at anytime during the claims process to allow us to complete the Social Security claim. Therefore, you need to contact us by the respond by date above to complete a supplemental application so that we can obtain additional information to pay you Social Security benefits (or a higher Social Security benefit).

If you do not provide the necessary information we request by this date:

  • You will not be eligible for SSI.

  • You will have to pay back any SSI you may have received beginning ____________.

  • We will send you another letter explaining our decision and what you can do if you think we are wrong before we take any action on your SSI claim.

Please contact the Social Security office shown above to make an appointment to complete a supplemental application for Social Security benefits or if you have any questions.

Manager_________________________________________________________________________________Form SSA-L8051-U3 (6-2005)

B. Exhibit of Second Page - Field Office Copy

SOCIAL SECURITY ADMINISTRATION

Supplemental Security Income

Referral Notice for Social Security Benefits

                                                                                     Office Address:

                                                                                             Office Hours:

                                                                                     Telephone Number:

                                                                                      Date:

                                                                                      Respond by Date:

                                                                                      Claim Number:                                                                                 Manager_________________________________________________________________________________Form SSA-L8051-U3 (6-2005)                                   FIELD OFFICE COPY

C. Exhibit of Third Page - Field Office Title II Adjudicator Copy

SOCIAL SECURITY ADMINISTRATION

Supplemental Security Income

Referral Notice for Social Security Benefits

                                                                              Office Address:

                                                                                     Office Hours:

                                                                              Telephone Number:

                                                                              Date:

                                                                              Respond by Date:

                                                                              Claim Number:

TO BE COMPLETED __Ineligible __Refused to Apply __Will Contact Person

BY THE

TITLE II CLAIMS ____ Expect Decision ___Claim Approved

REPRESENTATIVE by ____________