Step 2: If recipient does not respond in 35 days, send an SSA-L8165 (Supplemental
Security Income Notice of Decision) to the taxpayer with a completed SSA-2495. Use
the following language:
We are writing to tell you that we received information from computer matching with
the Internal Revenue Service (IRS) that may affect (1) eligibility for Supplemental Security Income (SSI) benefits.
We learned that you have (2) . We cannot discuss this with (3) without your permission.
How to make an appointment
Please contact (4) at (5) for an appointment to discuss this information at the address shown above. If you
cannot come in, please sign the enclosed form and return it to this office.
What you will need
Please bring any records you have about (6) discussed above. We must see the original document(s) or a certified copy. We cannot
accept photocopies. We will not keep any of your papers.
We need to hear from you even if you do not have the records. We will help you get
the information that you do not have.
If we do not hear from you
If we do not hear from you within 30 days from the date of this letter, we will send
a letter to (3) explaining that (7) Supplemental Security Income (SSI) payments will stop. The letter will also explain
(1) right to question our planned action if (8) thinks we are wrong.
If you have any questions
We will be glad to answer any questions you have. Contact (4) at (5) , or bring your questions to the appointment.
Name of recipient in possessive form, e.g., Mrs. Joan Smith's
Specify income or resources and give amount and period
Name of field office (FO) contact
Local FO telephone number
Specify income or resources
Choice 1: her
Choice 2: his
Choice 1: she
Choice 2: he