TN 56 (10-07)

SI 02305.003 Alternative Signature Methods: Attestation and Witnessed Signature

A. Background

The Agency has adopted alternative signature methods to the traditional pen-and-ink, or wetsignature. For redetermination (RZ) processing the two approved signature alternatives are attestation and witnessed signature.

Alternative signature methods are used in the Modernized Supplemental Security Income Claims System (MSSICS). RZs completed by third parties, other than representative payees, are excluded from the alternative signature process.

Alternative signature methods cannot be used with cases excluded from MSSICS. For these cases the signed paper RZ form must be retained.

NOTE: All references to redeterminations and/or RZs also apply to amendments to redeterminations.

B. Attestation

Attestation is the action taken by an Agency employee of confirming and annotating on MSSICS the SSI individual's:

  • Affirmation under penalty of perjury that the information provided is correct;

  • Intent to file the RZ or the amendment to the RZ; and

  • Agreement to sign the redetermination form.

C. Witnessed Signature

Witnessed signature is the action taken by an Agency employee of annotating MSSICS that he or she received a paper redetermination or amendment with a pen-and-ink signature, and the SSI individual had not previously signed the RZ by attestation. Once the annotation is made, the signed paper form is not retained in the RZ file. Instead, it is returned to the individual with the appropriate cover notice.

D. Policy - Attestation

For personal contact RZs (SI 02305.031A.) the interviewer:

  • confirms the SSI individual's intent to complete and sign the RZ;

  • provides a copy and reviews the penalty clause; and

  • attests to the individual's agreement to sign the RZ by annotating the ATTEST issue in MSSICS per SI 02305.003E..

The act of attesting to these facts is documentation of the individual's signature. Attestation is deemed equivalent to a wet signature.

E. Policy - Witnessed Signature

When a paper or printout RZ is filed with a pen-and-ink signature and the SSI individual has not previously signed the application or another RZ by attestation, an Agency employee will annotate MSSICS by receipting in the ATTEST issue in the development worksheet (DW01) screen. This documents that the employee received the RZ form containing a pen-and-ink signature. The electronic annotation is deemed equivalent to a pen-and ink signature. Once the annotation is made, the signed paper form is not retained in the RZ folder. The form is returned to the individual with the appropriate cover notice.

F. Procedure - Attestation

Use attestation as the signature for RZs processed in MSSICS. If the SSI individual or representative payee insists on signing the RZ with a pen-and-ink signature (or if you have a “wet” signature RZ initiated prior to 11/20/2004), follow witnessed signature procedures once you receive the signed RZ. See SI 02305.003D.

1. Interviewer Responsibilities

Print a cover notice with the RZ summary ONLY when requesting evidence. See GN 00201.015F.1.f.

Interviewer responsibilities are the same for RZs as they are in Title XVI applications. Interviewers must:

  1. Inform SSI individuals that a pen-and-ink signature is no longer required for personal contact (SI 02305.031A.) RZs processed in MSSICS.

  2. Explain to SSI individuals that the interviewer will confirm:

    • the individual's intent to provide requested information to the Agency to enable the Agency to determine continuing SSI eligibility; and

    • the information the individual supplied is correct under penalty of perjury; and

    • the individual's agreement to sign the RZ form.

  3. Read the scripted language in SI 02305.003F.2 and SI 02305.003F.3.

  4. Confirm the individual's intent to complete and sign the RZ.

  5. Complete the RZ form.

Review the penalty of perjury language with the individual SI 02305.003F.3.

Provide the individual with a copy of the RZ cover notice (see SI 02305.003G.1.) containing the penalty of perjury language. This RZ cover notice can be printed from the Print Options (DPRN) screen in MSSICS.

NOTE: Print an automated personalized cover notice with the RZ summary ONLY if you are requesting evidence.

You must print the RZ cover notice before you post the receipt of the RZ. If you do not, you will not be able to print the RZ personalized cover notice from MSSICS; you will have to prepare a Distributed Online Correspondence System (DOCS) notice instead.

2. Attestation - Face-to-Face - Interviewer's RZ Script

a. English Language Version

Start of the interview

“During this interview, we are going to ask you questions to make sure that you/name of recipient still qualify (qualifies if name of recipient is used) for SSI benefits. At the end of the interview we will ask you to confirm the truthfulness of your answers under penalty of perjury. We will record your response. You should be aware that you can be held legally responsible if you give us false or misleading information.”

End of the interview — Review of printed output

“Here is a printed copy of the information that will be used to determine if you/name of recipient still qualify (qualifies if name of recipient is used) for SSI benefits. Please review all the information carefully and let us know right away if anything needs to be corrected or if any of the information changes.”

Obtain affirmation of the individual's intent to complete the RZ form and his/her understanding of the penalty clause

“Do you understand that the information you gave us and that you examined will be used to determine if you/name of recipient still qualify (qualifies if name of recipient is used) for SSI? Do you declare under penalty of perjury that this information is true and correct to the best of your knowledge?”

b. Spanish Language Version - In-person Interviewer's Script

“Durante esta entrevista, le haremos unas preguntas para asegurarnos que (Usted ó el nombre de la persona que recibe beneficios) todavía esta elegible para beneficios de Seguridad de Ingreso Suplementario (SSI). Al terminar la entrevista, le pediremos que confirme la veracidad de sus respuestas bajo penalidad de perjurio y anotaremos su respuesta. Usted deberá estar consciente de que Usted podrá ser legalmente responsable si nos da información falsa.”

“Aquí esta una copia impresa de la información que se usara para determinar si (Usted ó el nombre de la persona que recibe beneficios) todavía esta elegible para beneficios de Seguridad de Ingreso Suplementario (SSI). Por favor revise toda la información cuidadosamente y avísenos inmediatamente si algún dato necesita ser corregido Ó si alguna información cambia.”

“¿Entiende Usted que la información que nos ha dado y ha revisado será usada para determinar si (Usted ó el nombre de la persona que recibe beneficios) todavía esta elegible para beneficios de Seguridad de Ingreso Suplementario (SSI)? ¿Declara Usted bajo penalidad de perjurio que esta información es verídica y correcta según su conocimiento?”

3. Attestation - Telephone Interview - Interviewer's RZ Script

a. English Language Version

Start of the interview

“During this interview, we are going to ask you questions to make sure that you/name of recipient still qualify (qualifies if name of recipient is used) for SSI benefits. At the end of the interview we will ask you to confirm the truthfulness of your answers under penalty of perjury. We will record your response. You should be aware that you can be held legally responsible if you give us false or misleading formation.”

End of the interview — Review of printed output

“You will receive a printed copy of the information that will be used to determine if you/name of recipient still qualify (qualifies if name of recipient is used) for SSI benefits. Retain this summary for your records. Review all the information carefully and let us know right away if anything needs to be corrected or if any of the information changes.”

Obtain affirmation of the individual's intent to complete the RZ form and his/her understanding of the penalty clause

“Do you understand that the information you have provided will be used to determine if you/name of recipient still qualify (qualifies if name of recipient is used) for SSI? Do you declare under penalty of perjury that this information is true and correct to the best of your knowledge?”

b. Spanish Language Version - Telephone Interviewer's Script

“Durante esta entrevista, le haremos unas preguntas para asegurarnos que (Usted ó el nombre de la persona que recibe beneficios) todavía esta elegible para beneficios de Seguridad de Ingreso Suplementario (SSI). Al terminar la entrevista, le pediremos que confirme la veracidad de sus respuestas bajo penalidad de perjurio y anotaremos su respuesta. Usted deberá estar consciente de que Usted podrá ser legalmente responsable si nos da información falsa.”

“Usted recibirá una copia impresa del resumen de la información que se usara para determinar si (Usted ó el nombre de la persona que recibe beneficios) todavía esta elegible para beneficios de Seguridad de Ingreso Suplementario (SSI). Guarde esta aplicación para retener para sus archivos. ¿Entiende Usted que debe revisar toda esta información cuidadosamente y nos deberá avisar si algo necesita ser corregido Ó si alguna información cambia?”

“¿Entiende Usted que la información que nos ha dado será usada para determinar si (Usted ó el nombre de la persona que recibe beneficios) todavía esta elegible para beneficios de Seguridad de Ingreso Suplementario (SSI)? ¿Declara Usted bajo penalidad de perjurio que esta información es verídica y correcta según su conocimiento?”

4. Documentation Requirements

The ATTEST issue automatically propagates to the DWO1 and should be receipted in with the date of the attestation interview. Based on your personal identification number (PIN), the first six letters of your surname and first initial will propagate to the Remarks section of the DW01 screen. The ATTEST issue and your name will be retained electronically in the REMARKS field of the ATTEST issue. This will be deemed the equivalent of the individual's signature on the RZ form.

When a pen-and-ink signature is received, annotate MSSICS by receipting the ATTEST issue. Return the signed RZ form to the SSI individual. Use the witnessed signature RZ cover notice (See SI 02305.003G.2.). This RZ cover notice informs the individual that the Agency will not retain the paper RZ form.

5. Amendments

When the SSI individual/payee makes changes or corrections to the RZ summary and answers affecting payment amount or eligibility are changed, an amendment is required. See the list below. Printing an amendment for other changes is not required.

a. Changes that Require an Amendment

Following is a list of changes that require an amendment:

  • Alien Status (AALN)

  • U.S. Citizenship Status (ACIT)

  • Allegations of holding out

  • County/Felony (ALEF)

  • Date of Alien Status (AALN)

  • Date Warrant Issued (AWRT)

  • Date Warrant Satisfied (AWRT)

  • Felony/High Misdemeanor Status (ALEF)

  • Fugitive Felon Status (ALEF)

  • Parole or Probation Status (ALEF)

  • Parole or Probation Violation Status (ALEF)

  • Has the Marriage Ended (AMAR)

  • OS CA Cooking and Food Storage (LCAO)

  • OS CA Needs Assistance (LCAO)

  • OS MA Pays Two-Thirds (LMAO)

  • OS NJ All Meals OUT (LNJO)

  • OS NJ Separate Purchase Prep (LNJO)

  • OS NY All People Living With (LNYO)

  • OS NY Flat Fee (LNYO)

  • OS NY Separately Prep All Food (LNYO)

b. Actions Required When an Amendment is Required

If the summary is returned with substantive changes or if the individual/payee calls/visits to report substantive changes that require a signature, follow the attestation procedures in SI 02305.003F. Also:

  • Update the record with the correct information.

  • Print the RZ amendment.

  • Give or send the RZ amendment to the individual. Use the automated RZ personalized cover notice from the DPRN screen in MSSICS (see SI 02305.003G.1.) with penalty of perjury language. For witnessed signature RZs, see SI 02305.003F. For the witnessed signature cover notice, see SI 02305.003H.2.

  • Document the ATTEST issue; see SI 02305.003F.4.

G. Procedure – Witnessed Signature

1. When Witnessed Signature May Apply

Witnessed signature may apply if the SSI individual insists on signing with a pen-and-ink signature. Scripted language is not used with a witnessed signature case.

NOTE: For RZs completed by telephone, mail the RZ for signature using the RZ cover notice (see SI 02305.003G.2.). Apply witnessed signature procedures to all pen-and-ink RZs received after 11/24/2006.

2. Signed Redetermination Received

When a completed RZ or summary RZ signed with a pen-and-ink signature is received (and the RZ was not signed via attestation) the interviewer will:

  • Annotate MSSICS by receipting the ATTEST issue to show that the RZ was signed with a pen and ink (“wet”) signature.

  • Return the signed RZ to the SSI individual using the witnessed signature RZ cover notice (see SI 02305.003G.2. and GN 00201.015K.). The notice will inform the individual that the Agency will not retain the paper RZ.

  • Clear the RZ if all required evidence has been received and all determinations have been completed. If further development is required, continue to process the case.

H. Exhibits

1. Exhibit - Redetermination Cover Notice (Instructions for Completing the Notice Follow the Exhibit)

Social Security Administration

Supplemental Security Income

Important Information

                                                                                    Office Address

                                                                                    Office Hours:

                                                                                    Telephone:

                                                                                    Date: March 2, 2005

                                                                                    Social Security Number:

                                                                                                  123-00-6789

On__(1)________, we talked with you and completed ____ (2)_____ redetermination for Supplemental Security Income (SSI). We stored your redetermination electronically in our records. Attached is a summary of your statements for your review.

What You Need to Do

  • Review your redetermination summary to ensure we recorded your statements correctly.

  • If you agree with all your statements, you may retain the redetermination summary for your records.

  • If you disagree with any of your statements, you should contact us by ______(3)_____ to let us know.

  • Send us the information requested below under What We Need. (Optional bullet used when evidence is requested)

IMPORTANT REMINDER

Penalty of Perjury

You declared under penalty of perjury that you examined all the information on the redetermination summary and it is true and correct to the best of your knowledge. You were told that anyone who knowingly gives a false or misleading statement about a material fact in an electronic redetermination, or causes someone else to do so, commits a crime and may be sent to prison or may face other penalties, or both.

What We Need (optional paragraph)

We need the items listed below to decide if we have correctly paid you. Please bring or mail these items to us right away. Our address and phone number are shown at the top of this notice. The sooner we receive the item(s), the sooner we can determine if we have paid you correctly and if your eligibility continues.

We must see the original document(s) or a certified copy of the item(s). We cannot accept photocopies except for tax returns. We will return the item(s) to you.

INF011 Request for life insurance policies (Used as an example)

If We Do Not Hear From You

If you do not respond to our request for information or evidence or contact us by _(4)___________, we may stop your SSI. 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.

Information About Medicaid

In many States, getting SSI means you are also getting Medicaid. If we stop your SSI, you cannot get Medicaid based on SSI.

If You Have Any Questions

If you have any questions, you may call, write or visit any Social Security office. If you call or visit, please have this letter with you and ask for_______(5)________________. The telephone number is shown at the top of this letter. We can answer most questions over the phone.

Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly.

                                                                                              Manager

Enclosure(s):

Redetermination Summary

Return envelope

Fill-in 1

Date of Interview (mm/dd/yyyy)

Fill-in 2

Choice 1 = “your”

Choice 2 = Recipient's name (if there is a representative payee)

Fill-in 3

10 days after the date of the notice (mm/dd/yyyy)

Fill-in 4      

30 days after the date of the notice (mm/dd/yyyy)

Fill-in 5

Claims Representative's Name

2. Exhibit - Redetermination Witnessed Signature Cover Notice – (Instructions for Completing the Notice Follow the Exhibit)

Social Security Administration

Important Information

                                                                                   Office Address:

                                                                                   Office Hours:

                                                                                   Telephone:

                                                                                   Date:

                                                                                   Social Security Number:

                                                                                                  123-00-6789

We are returning the attached redetermination to you for your records.

We stored ___ (1)___ redetermination information and signature electronically so there is no reason for us to retain a paper copy of your redetermination.

IMPORTANT REMINDER

You declared under penalty of perjury that you examined all the information on the attached redetermination and it is true and correct to the best of your knowledge. You stated that you understood that anyone who knowingly gives a false or misleading statement about a material fact in this redetermination, or causes someone else to do so, commits a crime and may be sent to prison or may face other penalties, or both.

If You Have Any Questions

If you have any questions, you may call, write or visit any Social Security office. If you call or visit, please have this letter with you and ask for ________(2)_____________.

The telephone number is shown at the top of this letter. We can answer most questions over the phone.

Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly.

                                                                                                      Manager

Enclosure:

Redetermination

Fill-in 1

Choice 1 = “your”

Choice 2 = Recipient's name (if there is a representative payee)

Fill-in 1

Choice 1 = “your”

Choice 2 = Recipient's name (if there is a representative payee) This seems to duplicate the above fill-in choice.

Fill-in 2

Claims Representative's Name

I. References

GN 00201.015, Alternative Signature Methods


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0502305003