GN 01085.025 Exhibit - Retention Periods For Program-Related Forms

Exhibit

The following exhibit is to be used as a guide for discarding forms in a claims folder. Although many forms are displayed, this is not an all-inclusive list. Additional forms and any changes to current retention periods will be added in future updates. The retention information was extracted from pertinent sections of the Administrative Instructions Manual System (AIMS), the Materiel Resources Manual - Chapter 07, and the Records Management Handbook, and from a policy review of the program-related forms currently mentioned in certain sections of the POMS. The exhibit provides form numbers in numerical order with titles and retention periods. Note that, unless otherwise annotated, all forms with a multiple suffix (e.g., F6, SP, U2, etc.) have the same retention disposition as the basic numeric form.

FORM NUMBER	TITLE	RETENTION DISPOSITION
SSA-1	Application for Retirement Benefits	UNTIL paper claims file is destroyed.
SSA-2-F6	Application for Spouse Insurance Benefits	UNTIL paper claims file is destroyed.
SSA-3	Marriage Certification	UNTIL paper claims file is destroyed.
SSA-4-BK	Application for Child Insurance Benefits	UNTIL paper claims file is destroyed.
SSA-5-F6	Application for Mother or Father Insurance Benefits	UNTIL paper claims file is destroyed.
SSA-7-F6	Application for Parent Insurance Benefits	UNTIL paper claims file is destroyed.
SSA-8-F4	Application for Lump Sum Death Payment	PAPERLESS LSDP ONLY CLAIMS Destroy 60 DAYS after verification of systems acceptance of LSDP action. ALL OTHER LSDP / SURVIVOR CLAIMS UNTIL paper claims file is destroyed.
SSA-10-BK	Application for Widow(er) Insurance Benefits	UNTIL paper claims file is destroyed.
SSA-11-BK	Request to be Selected as Payee	UNTIL paper claims file is destroyed.
SSA-16-F6	Application for Disability Insurance Benefits	UNTIL paper claims file is destroyed.
SSA-19-F6	Application for Special Age 72-or-Over Monthly Payments	UNTIL paper claims file is destroyed.
SSA-21	Supplement of Claim of Person Outside the U.S.	UNTIL paper claims file is destroyed.
VA-21-4182	Abbreviated Application for VA Benefits	Do NOT retain unless used for protective filing; then retain UNTIL paper claims file is destroyed.
VA-21-8046	VA Payment Notice (Stop-Suspend-Resume)	Do NOT retain.
SSA-24	Application for Survivor Benefits	UNTIL paper claims file is destroyed.
SSA-25	Certificate of Election for Reduced Spouse Benefits	UNTIL paper claims file is destroyed.
BRI-46-289	Inquiry from OPM	Do NOT retain.
VA-70-7210	Request for Index and Locator Information	Do NOT retain.
SSA-101-U3	Determination of Award - Manual	UNTIL paper claims file is destroyed.
SSA-L106	School Certification of Birth Data	Destroy 120 DAYS after receipt and verification of systems acceptance or the discrepancy is closed.
SSA-122	Request for Additional Information	Do NOT retain.
SSA-149	Waiver of Benefit Payments.	UNTIL paper claims file is destroyed.
SSA-150	Modified Benefit Formula Questionnaire for the Windfall Elimination Provision (WEP)	UNTIL paper claims file is destroyed.
SSA-174	Representative Payee Diary Card	Do NOT retain.
SF-180	Request Pertaining to Military Service Records	Do NOT retain.
SSA-208	Authorization for Garnishment	UNTIL paper claims file is destroyed.
SSA-209	Garnishment Information Update	UNTIL paper claims file is destroyed.
DD-214	Statement of Military Service	UNTIL paper claims file is destroyed.
SSA-L244	Letter Transmitting Reconsideration Determination	Destroy 120 DAYS after verification of systems acceptance of the reconsideration decision.
SSA-250	Development Worksheet	Destroy 120 DAYS after completion of development.
SSA-L250	Notice of Application for Withdrawal of Claim	UNTIL paper claims file is destroyed.
SSA-L293-U2	RSDI Notice of Unscheduled CDR	Do NOT retain.
SSA-381-SP	Waiver of Option to Receive Spanish Language Notice	UNTIL paper claims file is destroyed.
SSA-385	OIO Case Folder Flag	Destroy when case is returned to OIO.
SSA-408	Route Slip	Do NOT retain.
SSA-409	Postadjudicative Routing	Do NOT retain.
SSA-450	Claims Input Data Form	Destroy 30 DAYS after verification of systems acceptance.
SSA-454-BK	Report of Continuing Disability Interview	UNTIL paper claims file is destroyed.
SSA-455	Disability Update Report	UNTIL paper claims file is destroyed.
SSA-492	PC Case Folder Flag	Destroy when claim is returned to appropriate PC.
HA-520-U5	Request for Review of Hearing Decision/Order	Destroy 120 DAYS after final ODAR decision.
SSA-521	Request for Withdrawal of Application	UNTIL paper claims file is destroyed.
SSA-533	Translation Request	UNTIL paper claims file is destroyed.
HA-539	Notice Regarding Substitution of Party (Upon Death of Claimant)	Destroy 120 DAYS after death of claimant.
SSA-546	Workers' Compensation/Public Disability Benefits Information	UNTIL paper claims file is destroyed.
SSA-553	Special Determination	UNTIL paper claims file is destroyed.
SSA-559	Transmittal Sheet for Claims Folder/Material	Do NOT retain unless used for adjudication; then retain UNTIL paper claims file is destroyed.
SSA-561-U2	Request for Reconsideration	UNTIL paper claims file is destroyed.
SSA-562-U3	Request for Assistance/ Certification of Documents or Records	UNTIL paper claims file is destroyed.
SSA-L566	SSA Application Development	Destroy 120 DAYS after receipt and verification of systems acceptance or the discrepancy is closed.
SSA-573	Special Typing Instructions	Do NOT retain unless language is unavailable elsewhere; then retain UNTIL paper claims file is destroyed.
SSA-622-SM	Representative Payee Questionnaire –Individual	Destroy 30 DAYS after verification of systems acceptance.
SSA-623-F6	Representative Payee Report	UNTIL paper claims file is destroyed.
SSA-623-OCR-SM	Representative Payee Report	Destroy 30 DAYS after verification of systems acceptance.
SSA-624-F5	Representative Payee Evaluation Report	UNTIL paper claims file is destroyed.
SSA-625	Report by Former Representative Payee	UNTIL paper claims file is destroyed.
SSA-632-BK	Request for Waiver of Overpayment Recovery or Change in Repayment Rate	UNTIL paper claims file is destroyed.
SSA-632-SUP	Recovery Interview Supplement	UNTIL paper claims file is destroyed.
SSA-635	Waiver Determination	UNTIL paper claims file is destroyed.
SSA-636-U3	Transmittal Notice for a Hearing	Do NOT retain.
SSA-654-U4	Request for Information From Uniformed Services	UNTIL paper claims file is destroyed.
SSA-655-U2	Certification by Federal Agency	UNTIL paper claims file is destroyed.
SSA-656	Information as to Continuing Eligibility Under Title 38 USC, Section 412, Veterans' Benefits	UNTIL paper claims file is destroyed.
SSA-662	Reconsideration Determination	UNTIL paper claims file is destroyed.
SSA-702	Statement Regarding Date of Birth and Citizenship	UNTIL paper claims file is destroyed.
SSA-704	Certification of Contents of Document(s) or Record(s)	Destroy 120 DAYS after receipt and verification of systems acceptance or the discrepancy is closed.
SSA-L706	Proof of Age Letter to Custodian	Destroy 120 DAYS after receipt and verification of systems acceptance or the discrepancy is closed.
SSA-721	Statement of Death By Funeral Director	PAPERLESS LSDP ONLY CLAIMS Do NOT retain. ALL OTHER LSDP / SURVIVOR CLAIMS UNTIL paper claims file is destroyed.
SSA-723-F4	Statement Regarding Presumed Death Due to Unexplained Absence	UNTIL paper claims file is destroyed.
SSA-L725	Employer Verification of Monthly Wages (see OS 15010.347)	UNTIL paper claims file is destroyed.
SSA-730-U2	Request to Have SSI Overpayment Withheld From SSA Benefits	UNTIL paper claims file is destroyed.
SSA-L732	Additional Information Needed From Claimant to Adjudicate Claim	Do not retain after receipt and verification of systems acceptance or the discrepancy is closed.
SSA-753	Statement Regarding Marriage	UNTIL paper claims file is destroyed.
SSA-754-F4	Statement of Marital Relations	UNTIL paper claims file is destroyed.
SSA-760-F4	Certificate of Support	UNTIL paper claims file is destroyed.
SSA-766	Statement of Self-Employment	Destroy 1 YEAR after verification of earnings record update or the discrepancy is closed.
SSA-768	Certification of Evidence of Wages	Destroy 120 DAYS after verification of earnings record update or the discrepancy is closed.
SSA-781	Certificate of Care and Responsibility for Welfare of Child Not In Applicants Custody	UNTIL paper claims file is destroyed.
SSA-783	Statement Regarding Contributions	UNTIL paper claims file is destroyed.
SSA-787	Physician/Medical Officer Statement	UNTIL paper claims file is destroyed.
SSA-788	Statement of Care and Responsibility for Beneficiary	UNTIL paper claims file is destroyed.
SSA-790-RR	Request for Railroad Earnings	UNTIL paper claims file is destroyed.
SSA-795	Statement of Claimant or Other Person	UNTIL paper claims file is destroyed.
SSA-827	Authorization to Release Medical Information to SSA	UNTIL paper claims file is destroyed.
SSA-828-U4	Request for Medical Information from VA	Do NOT retain.
SSA-829-U4	Request for Medical Information From Military Facilities or Records Center	Do NOT retain.
SSA-831-U3	DIB Determination and Transmittal Sheet	UNTIL paper claim or postentitlement file is destroyed.
SSA-832-U3	Cessation or Continuance of Disability/Blindness Determination and Transmittal - Title XVI	UNTIL paper claim or postentitlement file is destroyed.
SSA-833-U3	Cessation or Continuance of Disability/Blindness Determination and Transmittal - Title II	UNTIL paper claims file is destroyed.
SSA-892-U2	ESRD Medical Determination	UNTIL paper claims file is destroyed.
SSA-924	Folder Documentation	UNTIL paper claims file is destroyed.
SSA-1002-F3	Statement of Agricultural Employer for Years Before 1988	Destroy 120 DAYS after verification of earnings record update or the discrepancy is closed.
SSA-1003-F3	Statement of Agricultural Employer for Years After 1987	Destroy 120 DAYS after verification of earnings record update or the discrepancy is closed.
SSA-1099-SM	SS Benefit Statement	Do NOT retain.
SSA-1129-U3	Attorney Fee Case Past-Due Benefit Summary	UNTIL paper claims file is destroyed.
SSA-L1157-U2	Notice of Disability	Destroy 120 DAYS after date of the notice.
SSA-1178	Evaluation of Fee Petition	UNTIL paper claims file is destroyed.
SSA-1203	Determination of Benefits Payable After Offset (WC/PDB)	UNTIL paper claims file is destroyed.
SSA-1208	Keep Flag on Top	Destroy 30 DAYS after verification of systems acceptance or the discrepancy is closed.
DD-1300	Report of Casualty	UNTIL paper claims file is destroyed.
SSA-1314	Annual Report Data	Destroy 30 DAYS after verification of systems acceptance.
SSA-1323	Report On Individual With Childhood Impairment	UNTIL paper claims file is destroyed.
SSA-1372	Student's Statement Regarding School Attendance	UNTIL paper claims file is destroyed.
SSA-1383	Student Reporting Form – Changes	Destroy 30 DAYS after verification of systems acceptance.
SSA-1386-U2	Student's Statement Regarding Resumption of School Attendance	Destroy 120 DAYS after receipt and verification of systems acceptance.
SSA-1388-U2	Report of Student Beneficiary at End of School Year	Destroy 120 DAYS after receipt and verification of systems acceptance.
SSA-1390	Report of Student Beneficiary About to Attain Age 19	Destroy 120 DAYS after receipt and verification of systems acceptance.
SSA-1425	Reporting Changes That Affect SSA Payment	Destroy 30 DAYS after verification of systems acceptance.
SSA-1473	Request for Railroad Annuity Information	UNTIL paper claims file is destroyed.
SSA-1535-U3	Application for Search of Census Records	UNTIL receipt of requested evidence.
SSA-1588-OCR-SM	Beneficiary Recontact Report	Do NOT retain.
SSA-1671-U2	Transmittal of Critical Case	Do NOT retain.
SSA-1696-U4	Appointment of Representative	UNTIL paper claims file is destroyed.
SSA-1709	Request for Workers' Compensation/Public Disability Benefits Information	UNTIL paper claims file is destroyed.
SSA-1719	RSI Postentitlement Direct Input	Destroy 30 DAYS after verification of systems acceptance.
SSA-1719-B	SSI Postentitlement Direct Input	Destroy 30 DAYS after verification of systems acceptance.
SSA-1719-C	SSI Postentitlement Direct Input	Destroy 30 DAYS after verification of systems acceptance.
SSA-1719-NC	SSI Non-receipt Direct Input	Destroy 30 DAYS after verification of systems acceptance.
SSA-1720	Annual Report Direct Input	Destroy 30 DAYS after verification of systems acceptance.
SSA-1724	Claim for Amounts Due	UNTIL paper claims file is destroyed.
SSA-1826	Sample Itemized Statement of Earnings	Destroy 120 DAYS after earnings record update or the discrepancy is closed.
PHS-1867	Public Health Service DMW Credit Reporting Form	UNTIL paper claims file is destroyed.
SSA-2118-U2	Request for Document or Information	Destroy 120 DAYS after verification of systems acceptance or the discrepancy is closed.
SSA-2164	Work Notice Direct Input	Destroy 30 DAYS after verification of systems acceptance.
SSA-2417-C1	Determination of Benefit Rights	UNTIL paper claims file is destroyed.
SSA-2454	Offset Worksheet (WC/PDB) – Triennial Redetermination Previously Applied	UNTIL paper claims file is destroyed.
SSA-2455	WC/PDB Offset Worksheet – Disability	UNTIL paper claims file is destroyed.
SSA-2506-BK	Psychiatric Review Techniques	UNTIL paper claims file is destroyed.
SSA-2512	Pre-1957 Military Service-Federal Benefit Questionnaire	UNTIL paper claims file is destroyed.
SSA-2514	Claimant's Intent to File	UNTIL paper claims file is destroyed.
SSA-2519	Child Relationship Statement	UNTIL paper claims file is destroyed.
SSA-2521	Request for Priority Action	Do NOT retain.
SSA-2708	Request to Call or Visit the District Office	Do NOT retain.
SSA-2764	SALT Coding Sheet	Destroy 30 DAYS after verification of systems acceptance.
SSA-2795-U2	Determination of Resumption of Award	UNTIL paper claims file is destroyed.
SSA-L3044-C1	Social Security Notice to Employee	Do NOT retain.
SSA-3105	Important Information About Your Review Rights	UNTIL paper claims file is destroyed.
SSA-3368-BK	Disability Report	UNTIL paper claims file is destroyed.
SSA-3369-BK	Work History Report	UNTIL paper claims file is destroyed.
SSA-L3400-C1	Social Security Notice	Do NOT retain.
SSA-3428-U2	Determination of Disallowance	UNTIL paper claims file is destroyed.
SSA-3440-EP	Claims Collection Litigation Report	UNTIL paper claims file is destroyed.
SSA-3441-BK	Reconsideration Disability Report	UNTIL paper claims file is destroyed.
SSA-3601	MCS or Non-CAPS Routing Form	Do NOT retain.
SSA-3621	MBR Account/Benefit Data Change Form	Destroy 30 DAYS after verification of systems acceptance.
SSA-3643	Offset Worksheet (WC/PDB) – Triennial Redetermination	UNTIL paper claims file is destroyed.
SSA-3820-F6	Medical History and Disability Report	UNTIL paper claims file is destroyed.
SSA-3826-F4	Medical Report	UNTIL paper claims file is destroyed.
SSA-3827	Medical Report (Individual With Childhood Impairment)	UNTIL paper claims file is destroyed.
SSA-3881-BK	Questionnaire For Children Claiming SSI Benefits	UNTIL paper claims file is destroyed.
SSA-3885	Government Pension Questionnaire	UNTIL paper claims file is destroyed.
SSA-3926	Determination of Benefit Adjustment	UNTIL paper claims file is destroyed.
SSA-4078	Request for Earnings After Death	Do NOT retain.
SSA-L4107	Change of Address – Additional Information Needed	Do NOT retain.
SSA-4111	Certificate of Election for Reduced Widow(er) Benefit	UNTIL paper claims file is destroyed.
SSA-L4112-C1	Request for Employment Information	UNTIL paper claims file is destroyed.
SSA-L4157	Request for Earnings Information	Do NOT retain.
SSA-4162	Child-Care Dropout Questionnaire	UNTIL paper claims file is destroyed.
SSA-4164	Consent Form for a Representative Payee	UNTIL paper claims file is destroyed.
SSA-4184	Self-Employment/Corporate Officer Questionnaire	UNTIL paper claims file is destroyed.
SSA-4268-U4	Explanation of Determination	UNTIL paper claims file is destroyed.
SSA-4345	SSI Offset Worksheet Federal	UNTIL paper claims file is destroyed.
SSA-L4360-SP	SS Benefit Information	UNTIL paper claims file is destroyed.
SSA-4385	Certification of Contents of Court Records	GENERAL USE Destroy 120 DAYS after receipt and verification of systems acceptance or the discrepancy is closed. REP PAYEE GUARDIAN / CAPABILITY ISSUES AND PRISONER CASES UNTIL paper claims file is destroyed.
SSA-4500-U6	Federal Determination of Error in State's Wage Reports	Destroy 120 DAYS after verification of earnings record update.
SSA-4582-CD	Wage Suspense/Reinstate Card	Destroy 120 DAYS after verification of earnings record update.
SSA-4641-U2	Authorization for SSA to Obtain Personal Information	UNTIL paper claims file is destroyed.
SSA-4734-U8	Residual Physical Functional Capacity Assessment	UNTIL paper claims file is destroyed.
SSA-4734-F4-SUP	Mental Residual Functional Capacity Assessment	UNTIL paper claims file is destroyed.
SSA-5002	Report of Contact	UNTIL paper claims file is destroyed.
SSA-L5004	Acknowledgment of Misdirected Tax	Do NOT retain.
SSA-5015-U2	Diary and Listing Slip	Destroy after issue is resolved or followup diary prepared.
SSA-5016	Scouting Request – Pending Claim	UNTIL paper claims file is destroyed.
HA-5051-U3	Transmittal of ALJ's Decision or Dismissal to ODAR	Destroy 120 DAYS after verification of systems acceptance of decision.
SSA-5052	RSI Health Insurance Information Request	UNTIL paper claims file is destroyed.
SSA-L5114	Letter Notifying Self-Employed Claimant of Adjustment	UNTIL paper claims file is destroyed.
SSA-5526 U3	Request for Assistance – Disability	Destroy 120 DAYS after verification of systems acceptance or the discrepancy is closed.
SSA-5527-U3	Request for Assistance – Representative Payee	Destroy 120 DAYS after verification of systems acceptance or the discrepancy is closed.
SSA-6220-SM	Representative Payee Questionnaire -Institutions	Destroy 30 DAYS after verification of systems acceptance.
SSA-6230-F6	Representative Payee Report for Children	UNTIL paper claims file is destroyed.
SSA-6230-OCR-SM	Representative Payee Report for Children	Destroy 30 DAYS after verification of systems acceptance.
SSA-7000-U5	Notice of Determination of Self-Employment Income	UNTIL paper claims file is destroyed.
SSA-7004-SM	Request for Earnings and Benefit Estimate Statement	Do NOT retain unless used for protective filing; then retain UNTIL paper claims file is destroyed.
SSA-7005	Personal Earnings and Benefit Estimate Statement (PEBES)	Do NOT retain unless used for protective filing; then retain UNTIL paper claims file is destroyed.
SSA-7008	Request for Correction of Earnings	Destroy 4 YEARS after determination is made or the discrepancy is closed.
SSA-7010-U5	Notice of Determination of FICA Wages	Destroy 120 DAYS after verification of earnings record update.
SSA-7011-F4	Statement of Employer Regarding Earnings	Destroy 120 DAYS after verification of earnings record update or the discrepancy is closed.
SSA-L7013	Request to Employer for Wage Information	Destroy 120 DAYS after verification of earning record update or the discrepancy is closed.
SSA-L7014	Request for Earnings Information	Destroy 120 DAYS after verification of earnings record update or the discrepancy is closed.
SSA-L7015	Follow Up to SSA-L7014 Request	Do NOT retain.
SSA-7052	DO Record of Earnings Discrepancy Development	Destroy 120 DAYS after verification of earnings record update or the discrepancy is closed.
SSA-7057-U3	Request for Tax Return Information	UNTIL paper claims file is destroyed.
SSA-7104	Partnership Questionnaire	UNTIL paper claims file is destroyed.
SSA-7157-F4	Farm Arrangement Questionnaire	UNTIL paper claims file is destroyed.
SSA-7160	Employment Relationship Questionnaire	UNTIL paper claims file is destroyed.
SSA-7161	Foreign Enforcement Questionnaire	UNTIL paper claims file is destroyed.
SSA-7162	Foreign Enforcement Questionnaire	UNTIL paper claims file is destroyed.
SSA-7163	Questionnaire About Employment or Self-Employment Outside USA	UNTIL paper claims file is destroyed.
SSA-7774-SM	Underpayment Detection Annual Report	Destroy 30 DAYS after verification of systems acceptance.
SSA-8000-BK	Application for SSI - Long Form	UNTIL paper claims file is destroyed.
SSA-8001-F5	Application for SSI - Short Form	UNTIL paper claims file is destroyed.
SSA-8006-F4	Statement of Living Arrangements, In-Kind Support and Maintenance	UNTIL paper claim or postentitlement file is destroyed.
SSA-8008	Living Arrangement and In-Kind Support and Maintenance Guide	UNTIL paper claim or postentitlement file is destroyed.
SSA-8010-BK	Statement of Income and Resources	UNTIL paper claim or postentitlement file is destroyed.
SSA-8011-F3	Statement of Household Expenses and Contributions	UNTIL paper claim or postentitlement file is destroyed.
SSA-8202-F6	Statement for Determining Continuing Eligibility for SSI Payment	Destroy 7 YEARS after completion of the redetermination action.
SSA-8203-BK	Statement for Determining Continuing Eligibility for SSI Payment	UNTIL paper claim or postentitlement file is destroyed.
SSA-8299	Request for Special Age 72 Reinstatement	UNTIL paper claims file is destroyed.
SSA-8510	Authorization to SSA to Obtain Personal Information	UNTIL paper claims file is destroyed.
SSA-8740	Referral and Treatment Status of SSI Drug Addicts and Alcoholics	UNTIL paper claim or postentitlement file is destroyed.
SSA-9432	Notice Regarding Military Service Wage Credits	Do NOT retain.
SSA-9584-BK	State Mental Institution Policy	UNTIL paper claims file is destroyed.
SSA-9584-SUP	Certification by State Mental Institution	UNTIL paper claims file is destroyed.
SSA-L9778-SM	Work Report	Destroy 30 DAYS after verification of systems acceptance.
SSA-L9779-SM	Work Report	Destroy 30 DAYS after verification of systems acceptance.
SSA-L9780-SM	Work Report	Destroy 30 DAYS after verification of systems acceptance.
SSA-L9781-EP	Work Report	Destroy 30 DAYS after verification of systems acceptance.
NA-13041	Statement of Service	UNTIL paper claims file is destroyed.
NA-13047	Reply to Request for Information	Do NOT retain.
NA-13075	Questionnaire About Military Service	Do NOT retain.

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0201085025

GN 01085.025 - Exhibit - Retention Periods For Program-Related Forms - 01/02/2015
Batch run: 01/02/2015
Rev:01/02/2015

Program Operations Manual System (POMS)

GN 01085.025 Exhibit - Retention Periods For Program-Related Forms

Exhibit