Complete Part I and Part II F. of the SSA-L1103-U3 as follows:

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  Address block

  If you are faxing the request to the VARO, enter the VARO city and state in this block. If you are mailing the request, include the full VARO mailing address.

  If you are faxing the request to the PMC, line through “Regional Office” and enter, “Pension Management Center”, and include the city and state of the appropriate PMC.

• •

  Phone Number block

  Include your telephone number and fax number, labeled as such, for contact purposes and to enable the VA to fax the completed SSA-L1103-U3 back to you.

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  VA Claim Number block

  Enter the VA Claim Number (VACN) from the VA correspondence or checks (if available). Otherwise, obtain the VACN from the Supplemental Security Record (SSR). Do not include prefixes and suffixes added by SSA. For information on how to determine the VACN, see SM 02002.013.

  EXAMPLE: The SSR shows Mr. Miller's VACN as: XXXXXXXXXAL. (SSA added the prefix “8” and the suffix “AL” for systems purposes.) The claims representative completes the SSA-L1103-U3 entering, the VACN as: XXXXXXXXX.

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  Months VA Payments Were Issued In block

  Enter the period, in MM/YYYY format, for which the benefit information is needed in the spaces marked “From MO/YR” and “Thru MO/YR”.

• •

  Enter the necessary information in the remaining blocks of the form. Information required is self-explanatory.

  NOTE: 

  If an entry is unknown enter, “unknown”, in that block.

Complete Part II F. if you need VA payment information due to unusual medical expenses

Enter the appropriate date in Part II F. if you need information regarding VA payments received as a result of unusual medical expenses. For information regarding the VA payment adjustment for unusual medical expenses, see SI 00830.312.

Assume, absent evidence to the contrary, that the information provided by the VARO or PMC on the SSA-L1103-U3 is correct. If there is evidence to the contrary, reconcile the discrepancy by calling the VA official identified on the SSA-L1103-U3, if a phone number was provided. Otherwise, fax or mail another SSA-L1103-U3 requesting clarification.

REMINDER: In some situations, the VARO or PMC will correctly report no augmentation when dependents are obviously involved.

If the VARO or PMC indicates a VA payment is adjusted to recover an overpayment, follow the instructions in SI 00830.110.

Document the income determination electronically according to the procedures in GN 00301.285 through GN 00301.289.