TN 14 (04-11)

NL 00705.710 Cover Letter - Function Report - Adult (Form SSA-3373-BK) - Sample

                                                                      ***BARCODE***

    

AGENCY
LETTERHEAD

      

      

                                                                          Date: _______________

                                                                          Case ID: ____________

   

Addressee Name

Address Line 1

Address Line 2

City, State, Zip code

     

    

Dear (Mr. or Ms.) (Last name):

We are the office that makes disability decisions for Social Security. We are writing to you because we need more information about your daily activities.

Please complete the enclosed Function Report form. Return the completed form and this letter within 10 days of the date on this letter. Please use the enclosed postage-paid envelope, or you may fax it to us at the fax number shown below.

If you do not return the form by (month, day, year), we may decide your case based on the information we already have. This means that we could find that you are not disabled or that your disability has ended if you are already getting benefits.

If you have any questions about completing this form, please call the phone number shown below from Monday – Friday between 8:00 a.m. and 4:00 p.m.

Thank you for your help.

Mary Jones

Disability Examiner

1-XXX-XXX-XXXX

1-800-XXX-XXXX

1-XXX-XXX-XXXX (TTY/MCM)

1-XXX-XXX-XXXX (FAX)

Enclosure: Function Report – Adult Form (SSA –3373 - BK)

Return envelope

cc:


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900705710
NL 00705.710 - Cover Letter - Function Report - Adult (Form SSA-3373-BK) - Sample - 04/22/2011
Batch run: 04/22/2011
Rev:04/22/2011