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