TN 9 (02-07)
NL 00722.160 T2 Application Cover Letter With Attestation Summary
Cover Letter with Attestation Summary
|
Social Security Administration
Application Development
|
|
| |
|
| |
|
| |
|
| |
Telephone Number
Date:
|
| |
|
|
Applicant Name
Street address
City, State zip code
|
|
| |
|
| |
|
On [date], we talked with you and completed your application for [fill-in]. We stored
your application information electronically in our records and are enclosing a summary
of your statements.
What You Need To Do
-
•
Review the summary to ensure we recorded your statements correctly.
-
•
If you agree with all your statements, you may retain the information or your records.
-
•
If you disagree with any of your statements, you should contact us within 10 days
after the date of this notice to let us know.
-
•
Review the reporting responsibilities so you are aware of the changes or events that
you need to report to us.
-
•
Provide the additional information that is listed below under "What We Need".
IMPORTANT REMINDER
Penalty of Perjury
You declared under penalty of perjury that you examined all the information on this
form and it is true and correct to the best of your knowledge. You were told that
you could be liable under law for providing false information.
What We Need
We need the item(s) listed below to decide if you can receive benefits. We must see
the original document(s) or a certified copy of the item(s) from the custodian of
the original record(s). We cannot accept photocopies except for tax returns. We will
return the item(s) to you.
Please bring or mail these items to us right away. The sooner we receive the item(s),
the sooner we can decide if you are eligible.
|
Birth Certificate or religious record of age
Marriage Certification
Divorce or annulment Decree
Proof of death
Proof of tax/wage withholding
Evidence-citizenship/residence status
Proof needed with disability claim
Bank name, account number, and routing number for direct deposit
Request for pay stubs
Request for self-employment records
Request for workers’compensation award letter
SSA-827 Authorization
OTHER
OTHER
OTHER
OTHER
OTHER
|
If You Have Any Questions
If you have any questions, you should call, write or visit any Social Security office.
If you call or visit our office, please have this letter with you and ask for . The telephone number is shown above. We can answer most questions over the phone.
Also, if you plan to visit an office, you may call ahead to make an appointment. This
will help us serve you more quickly.
Manager
Enclosure (s):
Application Summary
Envelope