TN 31 (09-25)
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 use the enclosed return envelope or fax your completed form(s) to us at [DDS
fax number]. Please note the return address may be to a scanning center who works
with us. The
completed form(s) must include the barcode page on top of the form(s).
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: