The following information should be provided by the beneficiary when the beneficiary
contacts SSA to request relief based on the Fowlkes AR. See GN 02613.830B.1. for instructions on obtaining a request for Fowlkes AR relief statement from the beneficiary. Suggested language for the beneficiary
to use in the Fowlkes AR relief request is as follows:
The following sample is provided as a guide for obtaining information from the beneficiary
to determine if Fowlkes AR relief can be granted:
Sample of an SSA-795 Requesting Relief Under the Fowlkes AR
Please review the prior decision to [stop/deny] [my/Name of Beneficiary’s] [Social
Security/SSI] payments because of an outstanding warrant for [my/Name of Beneficiary’s]
arrest and make a new decision to resume [my/Name of Beneficiary’s] payments using
the Fowlkes v. Adamec AR.
[I/Name of Beneficiary] understand that beginning December 6, 2005, based on the Fowlkes v. Adamec AR, SSA will not stop paying Social Security benefits to persons unless
the person knows there is an outstanding felony warrant for their arrest, they do
not resolve the warrant, and the warrant was issued because they are fleeing from
justice. [I/Name of Beneficiary] fit this criterion and want [my/name of beneficiary’s]
benefits resumed.
[My/Name of Beneficiary’s] current residence address is:
[I/name of beneficiary] [have/has] lived at this address since: (MM/DD/CCYY)
[My/Name of beneficiary’s] current mailing address is:
[My/Name of beneficiary’] felony warrant information is as follows:
Warrant Number:
Date warrant issued:
State of issuance:
Criminal Charges on the warrant:
Reason [I/Name of beneficiary] did not satisfy the warrant:
Date of initial suspension or administrative review notice from SSA notifying me of
SSA’s decision to suspend my benefits because of this warrant: [MM/DD/CCYY]
Address where the SSA notice (initial or administrative review notice) was sent:
Signature of Beneficiary: Date Statement Signed:
IMPORTANT: After SSA makes a determination regarding the beneficiary’s request for relief based
on the Fowlkes AR, the FO will fax the SSA-795 to the appropriate PSC for imaging into the electronic
claims folder for the beneficiary. The imaged SSA-795 statement will be retained with
the electronic folder indefinitely.