TN 107 (08-09)

SI 00830.320 Form SSA-L1103-U3 (SSI Request for Information) to Obtain Information from the United States Department of Veterans Affairs (VA)

A. Background on the SSA-L1103-U3 (SSI Request for Information)

Form SSA-L1103-U3 (SSI Request for Information) is used to obtain benefit verification from the VA. Depending on the type of VA benefit the individual is receiving, the SSA-L1103-U3 request is sent to either the appropriate Veterans Affairs Regional Office (VARO) or VA Pension Management Center (PMC).

The VA also maintains call centers throughout the United States that provide certain current benefit amounts for veterans and surviving spouses. Information about payment history, augmentation, unusual medical expenses, aid and attendance, housebound allowances and educational benefits is not provided by phone.

B. When to send the SSA-L1103-U3 to the VARO

Fax the SSA-L1103-U3 to the appropriate VARO shown below in SI 00830.320H to verify any of the following VA benefits:

  • VA compensation benefits including augmentation and apportionment,

  • Unusual medical expenses related to compensation benefits,

  • Educational benefits,

  • Survivor benefits (before 10/01/2009),

  • Insurance policy verification, and

  • Filipino Veterans Equity Compensation Fund (FVECF) payment.

NOTE: If the VARO does not have faxing capability, mail the request to the VARO address shown below in SI 00830.320H.

REMINDER: Certain current month VA benefit amounts are available by calling the VA toll free number at 1-800-827-1000.

CAUTION: Aid and attendance or a housebound allowance is not income for SSI purposes. If the individual alleges receiving aid and attendance or a housebound allowance, verify the individual’s monthly compensation amount with the VARO. Do not use the individual’s VA check or award letter as verification of the monthly compensation amount since it may include the additional allowance. For additional information on VA aid and attendance or housebound allowances, see SI 00830.308.

C. When to send the SSA-L1103-U3 to the PMC

Fax the SSA-L1103-U3 to the appropriate PMC shown below in SI 00830.320I) to verify any of the following VA benefits:

  • Pension benefits including augmentation and apportionment,

  • Unusual medical expenses related to VA pension benefits, and

  • Survivor benefits (effective 10/01/2009).

IMPORTANT: Effective October 1, 2009, all survivor benefits will be handled by the PMCs rather than the VAROs.

REMINDER: Certain current month VA benefit amounts are available by calling the VA toll-free number at 1-800-827-1000.

CAUTION: Aid and attendance or a housebound allowance is not income for SSI purposes. If the individual alleges receiving aid and attendance or a housebound allowance, verify the individual’s monthly pension amount with the appropriate PMC. Do not use the individual’s VA check or award letter as verification of the monthly compensation amount since it may include the additional allowance. For additional information on VA aid and attendance or housebound allowances, see SI 00830.308.

D. Type of VA benefit is unknown

If the type of VA benefit is unknown, send the SSA-L1103-U3 to both the appropriate VARO and appropriate PMC.

E. Procedure for completing the SSA-L1103-U3

Complete Part I of the SSA-L1103-U3 as follows:

1. Complete Part I

Complete Part I and Part II F. of the SSA-L1103-U3 as follows:

  • Address block

    If you are faxing the request to the VARO, enter the VARO city and state in this block. If you are mailing the request, include the full VARO mailing address.

    If you are faxing the request to the PMC, line through “Regional Office” and enter, “Pension Management Center”, and include the city and state of the appropriate PMC.

  • Phone Number block

    Include your telephone number and fax number, labeled as such, for contact purposes and to enable the VA to fax the completed SSA-L1103-U3 back to you.

  • VA Claim Number block

    Enter the VA Claim Number (VACN) from the VA correspondence or checks (if available). Otherwise, obtain the VACN from the Supplemental Security Record (SSR). Do not include prefixes and suffixes added by SSA. For information on how to determine the VACN, see SM 02002.013.

    EXAMPLE: The SSR shows Mr. Miller's VACN as: XXXXXXXXXAL. (SSA added the prefix “8” and the suffix “AL” for systems purposes.) The claims representative completes the SSA-L1103-U3 entering, the VACN as: XXXXXXXXX.

  • Months VA Payments Were Issued In block

    Enter the period, in MM/YYYY format, for which the benefit information is needed in the spaces marked “From MO/YR” and “Thru MO/YR”.

  • Enter the necessary information in the remaining blocks of the form. Information required is self-explanatory.

    NOTE: If an entry is unknown enter, “unknown”, in that block.

2. Complete Part II F.

Complete Part II F. if you need VA payment information due to unusual medical expenses

Enter the appropriate date in Part II F. if you need information regarding VA payments received as a result of unusual medical expenses. For information regarding the VA payment adjustment for unusual medical expenses, see SI 00830.312.

F. Following up on the SSA-L1103-U3 request

If 30 days have elapsed since the original SSA-L1103-U3 request, send a second request to the VARO and/or PMC, as appropriate. Write “Second Request” at the top of the SSA-L1103-U3 follow-up copy.

NOTE: Due to VA workload constraints, the response time is taking between 45-60 days. See SI 00830.005A for the general rules for developing unearned income and SI 00830.007 for the developmental rules in post-eligibility situations.

G. Procedure for reviewing the completed SSA-L1103-U3

1. Review of the SSA-L1103-U3

Assume, absent evidence to the contrary, that the information provided by the VARO or PMC on the SSA-L1103-U3 is correct. If there is evidence to the contrary, reconcile the discrepancy by calling the VA official identified on the SSA-L1103-U3, if a phone number was provided. Otherwise, fax or mail another SSA-L1103-U3 requesting clarification.

REMINDER: In some situations, the VARO or PMC will correctly report no augmentation when dependents are obviously involved.

If the VARO or PMC indicates a VA payment is adjusted to recover an overpayment, follow the instructions in SI 00830.110.

2. Documenting the verified VA benefit information

Document the income determination electronically according to the procedures in GN 00301.285 through GN 00301.289.

H. List of VAROs

This list shows the VARO mailing address for each geographical area and the fax number, if applicable:

State

State

Address

Alabama

Connecticut

Delaware

District of Columbia

Florida

Georgia

Indiana

Kentucky

Maine

Maryland

Massachusetts

Michigan

Mississippi

New Hampshire

New Jersey

New York

North Carolina

Ohio

Pennsylvania

Rhode Island

South Carolina

Tennessee

Vermont

Virginia

West Virginia

Puerto Rico

Europe

Asia

Australia

Africa

Canada

Palau

Marshall Islands

The U.S. Virgin Islands

Federated States of Micronesia

Department of Veterans Affairs Evidence Intake Center

P.O. BOX 4444

Newnan, GA 30271-0020

Or fax your information to:

Toll Free: 844-531-7818

DID: 248-524-4260

Alaska

Arizona

Arkansas

California

Colorado

Louisiana

Hawaii

Idaho

Illinois

Iowa

Kansas

Oklahoma

Oregon

Minnesota

Missouri

Montana

Nebraska

Nevada

New Mexico

North Dakota

South Dakota

Texas

Utah

Washington

Wisconsin

Wyoming

Mexico

Central America

South America

The Caribbean

The Philippines

American Samoa

Guam

Northern Mariana Islands

Department of Veterans Affairs Evidence Intake Center

P.O. BOX 4444

Janesville, WI 53547-4444

Or fax your information to:

Toll Free: 844-822-5246

DID: 608-373-6690

I. List of VA PMCs

The following is a list of the three PMCs, the geographical areas under their jurisdiction, and their fax numbers.

Pension Management Center and geographic areas under jurisdiction

FAX Number

Philadelphia, PA

Connecticut

Delaware

District of Columbia

Florida

Georgia

Maine

Massachusetts

Maryland

New Hampshire

New Jersey

New York

North Carolina

Pennsylvania

Rhode Island

South Carolina

Vermont

Virginia

West Virginia

1–844–655–1604

Milwaukee, WI

Alabama

Arkansas

Illinois

Indiana

Kentucky

Louisiana

Michigan

Mississippi

Missouri

Ohio

Tennessee

Wisconsin

1–844–655–1604

St. Paul, MN

Alaska

Arizona

California

Colorado

Hawaii

Idaho

Iowa

Kansas

Minnesota

Montana

Nebraska

Nevada

New Mexico

North Dakota

Northern Mariana Islands

Oklahoma

Oregon

South Dakota

Texas

Utah

Washington

Wyoming

1–844–655–1604

J. References

GN 02820.001, The American Recovery and Reinvestment Act of 2009 (ARRA): Introduction

GN 02820.010, Title II Eligibility Under the American Recovery and Reinvestment Act of 2009 (ARRA)

GN 02820.020, SSI Eligibility Under the American Recovery and Reinvestment Act (ARRA) of 2009

SI 00810.310, How to Compute Countable Income

SI 00830.230, Unemployment Insurance Benefits

SI 01110.003, Resource Limits

SI 01320.000, Deeming of Income

SI 01330.000, Deeming of Resources

K. Exhibit of Form SSA-L1103-U3

To view this form, go to SSA-L1103-U3.