BASIC (12-92)

SI 02306.701 SSA-L8003-U2, Supplemental Security Income Request for Information

 

Social Security Administration

Supplemental Security Income

Request for Information (PE)

 

                   Office Address:

 

                   Office Hours:

 

                   Social Security Number:

 

                   Date:

 

 

 

This is a very important letter about keeping your Supplemental Security Income (SSI) case active. Please read it carefully. If there is anything you do not understand, please get in touch with us right away.

What You Need To Do

We need more information to decide if we can continue to pay you SSI. Please do the following (only the boxes marked apply to you):

  • Mail or bring us the information marked under the “Things We Need,” along with this letter as soon as possible.

  • Sign and date the enclosed form(s). Return the form(s) and this letter in the enclosed envelope as soon as possible.

  • We have set up an appointment for you on      at      . On that date:

    — Call us at      and ask for     .

    — We will call you at      . Let us know if this number is wrong.

    — Come to see us at        and ask for      .

If We Do Not Hear From You

We may stop your SSI if you don't respond to this request or contact us by      to tell us why. If we stop your SSI, you could also lose any Medicaid you have now.

Before we stop your SSI, we will send you another letter to explain our decision. The letter will also explain your right to appeal the decision and how to continue getting SSI during the appeal.

 

 

                  See Next Page         Form SSA-L8003-U2

                              Page 2 of 2

 

Things We Need

We need to see all of the items checked for      to the present. 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.

  • Bank statements: savings and checking accounts, and any other bank statements for     

  • Pension records from: the Department of Veterans Affairs, Railroad Retirement Board, Civil Service, State, military, private pensions for       

  • Pay stubs from work since     for       

  • For self-employment, last year's income tax return; if not available, all records that show last year's business income and expenses for         

  • Unemployment compensation payment records for        

  • Worker's compensation award letter for        

  • Life insurance policies for        

  • Burial contract agreement for     

  • Other

     

     

We must see the original document(s) or a certified copy of these item(s). We cannot accept photocopies. We will return these items to you.

If you call or come in, please have this letter with you.

If You Have Any Questions

If you have any questions or need help, please call us at     and ask for     .

 

 

                     Manager

 

Enclosure(s):