SI 02306.702 SSA-L8004-U2, Supplemental Security Income Request for Information (1619b)
Social Security Administration
Supplemental Security Income
Request for Information (1619b)
Social Security Number:
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
Although you don't get SSI now because of your earnings, we keep your SSI case active.
This means that if your earnings go down, we can restart your SSI faster. And if you
have Medicaid, you can usually keep it while you work.
To keep your case active, please do the following (only the boxes marked apply to
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 close your SSI case if you don't respond to this request or contact us by to tell us why. You could also lose any Medicaid you have now.
Before we close your SSI case, we will send you another letter to explain our decision.
The letter will also explain your right to appeal the decision and how to keep your
SSI case active during the appeal.
See Next Page Form SSA-L8004-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
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 .