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.
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;
Food stamps (in all States but California);
Medicaid transfer of assets;
Paperwork Reduction Act of 1995; and
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.