TN 26 (03-92)

SI 02305.815 SSA-L3075-U2, Supplemental Security Income Notice of Appointment 1619(b)


Social Security Administration

Supplemental Security Income

Notice of Appointment (1619b)


                   Office Address:


                   Social Security Number:





This is a very important letter about keeping your Supplemental Security Income (SSI) case active. Please read it carefully. If there is anything you do not understand, please get in touch with us right away.

You Have An Appointment

Although you don't get SSI now because of your earnings, we keep your SSI case active. This means that if your earnings go down, we can restart your SSI faster. And if you have Medicaid, you can usually keep it while you work.

To keep your case active, we must review it every year. We need information from you to make sure you still meet the SSI rules.

We have set up an appointment for you on      at      . On that date:

  • Call us at      and ask for      .

  • We will call you at     . Let us know if this number is wrong.

  • Come to see us at        and ask for     .

  • Your representative payee must come with you to the appointment.

If We Do Not Hear From You

We may close your SSI case if you don't respond to this request or contact us by      to tell us why. You could also lose any Medicaid you have now.

Before we close your SSI case, we will send you another letter to explain our decision. The letter will also explain your right to appeal the decision and how to keep your SSI case active during the appeal.


                  See Next Page

                                 Form SSA-L3075-U2

                              Page 2 of 2


Things We Need for the Appointment

When you talk with us, please try to have all of the items checked for      to the present. 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.

  • Bank statements: savings and checking accounts, and any other bank statements for     

  • Pension records from: the Department of Veterans Affairs, Railroad Retirement Board, Civil Service, State, military, private pensions for       

  • Pay stubs from work since     for      

  • For self-employment, last year's income tax return; if not available, all records that show last year's business income and expenses for         

  • Unemployment compensation payment records for       

  • Worker's compensation award letter for      

  • Life insurance policies for      

  • Burial contract agreement for       

  • Other



We must see the original document(s) or a certified copy of these item(s). We cannot accept photocopies. We will return these items to you.

When you call or come in, please have this letter with you.

If You Have Any Questions

If you have any questions or need help, please call us at     and ask for     .






                                 Forms SSA-L3075-U2

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SI 02305.815 - SSA-L3075-U2, Supplemental Security Income Notice of Appointment 1619(b) - 02/19/1997
Batch run: 02/19/1997