To view the form, go to SSA-L8009–U3.
Social Security Administration
Supplemental Security Income
Important Information (IC)
Social Security Number:
This letter is very important and could affect whether you can get Supplemental Security
Income (SSI). Please read it carefully. If there is anything you do not understand,
please get in touch with us right away.
What You Need To Do
We need more information to decide if we can pay you SSI. Therefore, it is important
that you do the following: (Only the checked boxes apply to you.)
[_] Mail or bring in the item(s) checked on page 2 along with this letter as soon
[_] Sign and date the enclosed form(s). Return the form(s) and this letter in the
enclosed envelope as soon as possible.
[_] Call __________________ and ask for _________________________________.
[_] We will call you on ____________________at ______________________. Please let
us know if this telephone number is wrong or if this is not a good time for you.
[_] Come to see us on _____________________ and ask for __________________. The office
address is at the top of this letter.
If we have asked to talk to you, it is because we need to discuss _________________
If We Do Not Hear From You
We may deny your application for SSI if you don’t respond to this request or contact
us by _____________________ to tell us why. If we deny your application, we will send
you another letter to explain our decision. The letter will also explain your right
(See Next Page)
Form SSA-L8009-U3 (7/95)
Use 8/92 Edition Until Exhausted
2 of 2
Information about Medicaid
In many States, applying for SSI means you also are applying for Medicaid. If we deny
your SSI application, you cannot get Medicaid based on SSI.
Things We Need
We need to see the items checked below for ______________________________
to the present. Even if you don’t have all of the information, we need to hear from
you. We will help you get anything you do not have.
[_] Bank statements: savings and checking accounts, and any other bank statements
[_] Pension records from: the Department of Veterans Affairs, Railroad Retirement
Board, Civil Service, State," military, private pensions for _______________________________________________________________
[_] Pay stubs from work since ____________________ for ___________________
[_] For self-employment, last year's income tax return; if not available, all records
that show last year's business income and expenses for _____________________________
[_] Unemployment compensation payment records for ____________________
[_] Worker's compensation award letter for ______________________________
[_] Life insurance policies for ___________________________________________
[_] Burial contract agreement for _______________________________________
[_] Other _____________________________________________________________
We must see the original document(s) or a certified copy of the item(s). We cannot
accept photocopies, except for income tax returns. We will return the item(s) to you.
If you call or come in, please have this letter with you.
If You Have any Questions
If you have any questions or need help, please call us at the telephone number at
the top of this letter and ask for ____________________________________.
Enclosure(s): Form SSA-LS009-U3 (7/95)