Social Security Administration
Supplemental Security Income
Date: March 2, 2005
Social Security Number:
On__(1)________, we talked with you and completed ____ (2)_____ redetermination for Supplemental Security Income (SSI). We stored your redetermination electronically in our records. Attached is a summary of your statements for your review.
What You Need to Do
Review your redetermination summary to ensure we recorded your statements correctly.
If you agree with all your statements, you may retain the redetermination summary for your records.
If you disagree with any of your statements, you should contact us by ______(3)_____ to let us know.
Send us the information requested below under What We Need. (Optional bullet used when evidence is requested)
Penalty of Perjury
You declared under penalty of perjury that you examined all the information on the redetermination summary and it is true and correct to the best of your knowledge. You were told that anyone who knowingly gives a false or misleading statement about a material fact in an electronic redetermination, or causes someone else to do so, commits a crime and may be sent to prison or may face other penalties, or both.
What We Need (optional paragraph)
We need the items listed below to decide if we have correctly paid you. Please bring or mail these items to us right away. Our address and phone number are shown at the top of this notice. The sooner we receive the item(s), the sooner we can determine if we have paid you correctly and if your eligibility continues.
We must see the original document(s) or a certified copy of the item(s). We cannot accept photocopies except for tax returns. We will return the item(s) to you.
INF011 Request for life insurance policies (Used as an example)
If We Do Not Hear From You
If you do not respond to our request for information or evidence or contact us by _(4)___________, we may stop your SSI. 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.
Information About Medicaid
In many States, getting SSI means you are also getting Medicaid. If we stop your SSI, you cannot get Medicaid based on SSI.
If You Have Any Questions
If you have any questions, you may call, write or visit any Social Security office. If you call or visit, please have this letter with you and ask for_______(5)________________. The telephone number is shown at the top of this letter. 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.
Date of Interview (mm/dd/yyyy)
Choice 1 = “your”
Choice 2 = Recipient's name (if there is a representative payee)
10 days after the date of the notice (mm/dd/yyyy)
30 days after the date of the notice (mm/dd/yyyy)
Claims Representative's Name