SOCIAL SECURITY ADMINISTRATION
Supplemental Security Income
Referral Notice for Social Security Benefits
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
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.