TN 35 (10-26)

NL 00705.730 Questionnaire Cover Letter

 

AGENCY LETTERHEAD

Date: [Fill-in]

Case ID: [Fill-in]

 

Addressee Name

Address Line 1

Address Line 2

City, State, Zip code

 

COVER LETTER

 

We are the office that makes disability decisions for the Social Security Administration. We are writing to you because we need more information about your/[Claimant's full name]'s condition, daily activities, or work history. (If sending to third party) [Claimant full name] gave us your name as a person who would be able to provide us with this information.

[Free form/Canned text]

What You Need To Do

Complete the enclosed form(s) with black or blue ink. We realize that some of the questions may not seem relevant to the case, but please answer all of the questions to the best of your ability.

Return the completed form(s) by [10 calendar days]. If you do not return the form(s), we may decide the case based on the information we already have in file. This means that we could find that you/he/she is/are not disabled based on our rules or that your/his/her disability has ended if you/he/she is/are already getting benefits.

How To Return The Form(s)

You may return the completed form(s) in one of the following ways:

• •

  Use the enclosed return envelope. Please note the return address may be to a scanning center who works with us.

• •

  Fax your completed form(s) to [DDS fax number]. Ensure the page with the barcode is on top of your form(s).

• •

  Go Digital! You can submit certain documents electronically to SSA with an online my Social Security account. Create or sign in to your account at www.ssa.gov/myaccount and select 'Upload Documents.'

If You Have Any Questions

If you have any questions or wish to provide more information, please call us at the phone number(s) shown below Monday-Friday between [DDS office open] and [DDS office close]. When you call or leave a message, please provide the Case ID: [case ID number], your name, (if third party) [Claimant full name]'s name, and a call back number.

Thank you for your help.

[Name]

[Phone Number]

[Fax Number]

 

Enclosure:

Multi-Language Insert (if enclosed)

[Form name]

Privacy Act and Paperwork Reduction Act Statements

Return envelope

cc: