TN 54 (11-06)

SI 02305.020 SSA-8202- F4-INST, “Important Facts About Your Supplemental Security Income” - RZ Instruction Sheet

A. When To Use

The SSA-8202-F4-INST is enclosed with mail out SSA-8202-BK RZs.

B. Description

The SSA-8202-F4-INST is a 4-page form folded to 3-3/4" 8-1/2". There are four versions of the form:

  • SSA-8202-F4-INST and SSA-8202-F4-SP-INST are the English and Spanish versions of the forms for use by all States except California. These versions include a food stamp message.

  • SSA-8202-F4-INST-NFS and SSA-8202-F4- INST-SP-NFS are the English and Spanish versions of the forms for use by California only. These versions do not include a food stamp message.

All versions of the form include information about:

  • Why we conduct RZs;

  • How to complete the SSA-8202-BK;

  • Timeframe for responding and the consequences of not responding;

  • Recipient reporting responsibilities;

  • Computer matching;

  • Food stamps (in all States but California);

  • Medicaid transfer of assets;

  • Paperwork Reduction Act of 1995; and

  • Privacy Act.

C. Procedure

Following is the procedure for use of the SSA-8202-F4-INST:

  • Put the month/day/year you are mailing the form in the DATE block of two copies of the SSA-8202-F4-INST.

  • Enclose a copy with the form SSA-8202-BK you are mailing to the recipient.

  • Retain the other copy in the file to document the 30-day timeframe for close-out purposes.

D. References

  • SI 02305.804 SSA-8202-F4-INST, Important Facts About Your Supplemental Security Income (FO, Food Stamp Version)


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0502305020
SI 02305.020 - SSA-8202- F4-INST, "Important Facts About Your Supplemental Security Income" - RZ Instruction Sheet - 07/11/2017
Batch run: 07/11/2017
Rev:07/11/2017