TN 4 (04-07)
SI 00604.120 Completing the "Receipt For Claim" and "Changes To Report" Tear-Off Page
The SSA-8000-BK contains a detachable "claims receipt" and "changes to report" (reporting instructions) page which provides the applicant with:
Written acknowledgment that a claim for SSI has been filed;
An estimate of the anticipated processing time after all necessary information is received;
The procedure to follow if a decision is not reached within the estimated processing time;
Information about the Privacy Act, computer matching and the penalty provision for not reporting timely;
Information about the burden estimate and the request for comments; and
A summary of the claimant's reporting responsibilities.
1. When/How to Complete
When the signed application is received, complete the "Receipt for Claim" and "Changes to Report" and give/mail it to the applicant.
2. Application Signed by Pen and Ink (Face-to-Face Interview)
Follow procedures in GN 00201.015H.2. See the steps below for completing the receipt for the paper SSA-8000-BK.
Enter the name(s) and SSN(s) of the claimant(s) in the space provided on the form.
EXCEPTION: When a representative payee files the application, enter the representative payee's name followed by the word "for" and the name(s) of the claimant(s).
Enter the date the claim is filed.
Enter the telephone number and address of the servicing FO.
Enter (in the blank underlined area of the narrative) the estimated number of days it will take to hear from us. (An estimate of the number of days required for processing may be based on regional or local guidelines.)
Explain the Paperwork/Privacy Act Notice and computer matching statements as well as the burden estimate and request for comments (see GN 03360.015 and MSOM MSSICS 024.002).
Review the reporting responsibilities and answer any questions the applicant may have about the requirements. Remind the applicant about the penalty provision for failure to make a timely report.
Complete the "Changes to Report:"
Tell the applicant that he/she should retain the "Changes to Report" page for later reference because:
3. Application Signed by Pen-and-Ink (Teleclaim)
Follow procedures in GN 00201.015H. See the steps below for completing the receipt the paper SSA-8000-BK.
1 - 7
Follow steps 1 - 7 in SI 00604.120B.2.
Detach tear-off page and retain it.
Upon receipt of the signed application form, follow procedures in GN 00201.015H.2. Provide the applicant with a cover note explaining the following:
The "Receipt for Claim" is enclosed; and
Purpose and importance of the "Changes to Report;" and
He or she must report changes because changes can affect payment. Call or write to the Social Security office identified on the "Receipt;".
GN 00201.015F.1.h, Application Signed by Attestation
MSOM MSSICS 024.002, Application Receipt and Reporting Responsibilities, MSSICS Printed Outputs
MSOM MSSICS 022.003, Application Summary for SSI Applications