Ssa-l8554-u3

SOCIAL SECURITY ADMINISTRATION OFFICE OF QUALITY PERFORMANCE PO BOX 804371 CHICAGO, IL 60680-4105

Date: June 6, 2011

Claim Number: XXX-XX-4337 A

xxxxx

FOR xxxxx

302 PEARL STREET FORTVILLE, IN 46040

Dear MS xxxxx

Each month the Social Security Administration (SSA) asks a few people, who get benefit payments, to help us make sure we pay everyone the correct amount of money. This month, we picked xxxxxx (for whom you are representative payee). We made this selection by chance, not for any other reason.

To make sure you receive the correct amount, I would like to telephone you and xxxx on Wednesday, July 20, 2011 at 09:00 AM.

I am with the Office of Quality Performance, which is a special reviewing section in SSA, and is separate from the office that processed Lisa’s claim. If you would like to verify that this is a legitimate letter, you can call SSA. The national toll-free number is (800) 772-1213.

What Will Happen When I Call You

• I will identify myself as shown on the bottom of this letter.

• I will ask you questions about LISA’s benefits.

• The Privacy Act Statement that allows this review is enclosed.

How You Can Get Ready For My Call

• I have enclosed a form with the items checked that you should have available.

• Please review the enclosed copy of the Earnings Record for the account on which LISA is receiving benefits.

• You may have a friend or relative present to help you during my call.

Please Return the Enclosed Form to Me

Please complete and sign forms SSA 8552 and SSA 2935-U3, and mail them to me in the enclosed envelope. You do not need a stamp.

If you have any questions, you may call me between 08:00 AM and 05:00 PM. My telephone number is (800) 521-3318 EX-4968. Thank you.

Sincerely,

xxxxx

Quality Reviewer

Enclosures:

Interview Confirmation Form (SSA 8552)

Information Needed Form

Earnings Record

Authorization Form (SSA 2935-U3)

Privacy Act Statement

Return Envelope

		Form Approved
Social Security Administration		OMB No. 0960-0189

PLEASE COMPLETE AND RETURN THIS FORM TO ME

Claim Number: XXX-XX- 4337 A

1. I / We will be available for your interview as scheduled.

	YES
	NO
	If NO, please phone me as soon as possible to set a better time.

2. My telephone number is: ( ) .

3 . My address is:

4 . Signature:

Date:

Form SSA-8552

INFORMATION NEEDED TO REVIEW YOUR SOCIAL SECURITY CLAIM

Claim Number: XXX-XX-4337 A

Please have documents or proof of the ITEMS CHECKED below available for your interview if you have them in your possession. This will help us complete the review of your claim more quickly. Information regarding any items that are not checked but may pertain to you should also be mentioned during the interview.

	Social Security or Medicare Card for      
	Birth or baptismal certificate recorded before you were age 5 – otherwise, at least two of the following documents are needed : school records, census records, delayed birth certificate, children’s birth certificates, family Bible, naturalization certificate, etc.
	Records of age will also be needed for      
	Marriage Certificate for you and      
	Divorce or annulment decrees for all prior marriages
	Death Certificates for      
	Social Security numbers for all former spouses
	Proof of military service
	Pay Slips or W-2 Forms for      
	Self-employment tax returns for      
	Other:      

Form SSA-85

THE EARNINGS RECORD

Claim Number: XXX-XX-4337  

Benefits are computed by giving credit for any earnings, since 1937, that were covered under the Social Security Act. As part of our review, we check the record for accuracy.

The earnings record shows yearly amounts for 1951 through recent years. In the years not shown, no earnings were reported to Social Security. Earnings during 1937 -- 1950 are shown as a separate total.

Please compare the earnings amounts to any records you have. Pay particular attention to:

• Years with no earnings

• Years with earnings much higher than the ones before and after them

• Years with earnings much lower than the ones before and after them

If you disagree with any of these earnings, please have your records available at the time of the interview. W2 forms are the best evidence of wages. Tax returns and proof of filing are the best evidence of self-employment earnings.

     

			Form Approved
Social Security Administration			OMB No. 0960-0189
AUTHORIZATION TO THE SOCIAL SECURITY ADMINISTRATION TO OBTAIN PERSONAL
	INFORMATION
BENEFICIARY'S NAME: xxxxx
SOCIAL SECURITY NUMBER: XXX-XX-4337
STREET ADDRESS: xxxxx 
CITY: FORTVILLE		STATE: IN	ZIP CODE: 46040

I authorize the Individual, Organization, or Agency listed below to disclose to the Social Security Administration information about me relating to a claim for Social Security benefits. I understand that this information will be kept confidential as required by the Social Security Act and the Privacy Act of 1974. This authorization shall remain in effect for no longer than 12 months from the date of my signature.

Name of Individual, Organization, or Agency:  
Address:    
City:  	State:  	Zip Code:  
Signature of Beneficiary (First name, middle initial, last name)		Date (Month, day, year)
(Write in ink)
SIGN
HERE
Signature of Representative Payee or Guardian	(First name, middle initial, last name)	Date (Month, day, year)
(Write in ink)
SIGN
HERE

Witnesses are required ONLY if this authorization has been signed by mark (X) above. If signed by mark (X), two witnesses to the signing who know the applicant must sign below, giving their full addresses.

Signature of Witness	(First name, middle initial, last name)	Date (Month, day, year)
(Write in ink)
SIGN HERE
ADDRESS
Signature of Witness	(First name, middle initial, last name)	Date (Month, day, year)
(Write in ink)

SIGN HERE ADDRESS

Form SSA-2935-U3 (06-2008)

PRIVACY ACT STATEMENT

Privacy Act Statement

Collection and Use of Personal Information

Section 205 of the Social Security Act, as amended, authorizes us to collect this information. We will use the information you provide on this form to obtain information from another individual, organization, or agency regarding your Social Security benefits.

Completion of this form is voluntary; however, failure to provide all or part of the information could prevent us from correctly reviewing your Social Security benefits.

We rarely use this information you supply for any purpose other than for reviewing your claim for Social Security benefits. However, we may use it for the administration and integrity of Social Security programs. We may also disclose information to another person or to another agency in accordance with approved routine uses, which include but are not limited to the following:

1. To enable a third party or an agency to assist Social Security in establishing rights to Social Security benefits and/or coverage;

2. To comply with Federal laws requiring the release of information from Social Security records (e.g., to the Government Accountability Office and Department of Veterans’ Affairs);

3. To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level; and,

4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity and improvement of Social Security programs.

We may also use the information you provide in computer matching programs. Matching programs compare our records with records kept by other Federal, State, or local government agencies. Information from these matching programs can be used to establish or verify a person’s eligibility for Federally-funded or administered benefit programs and for repayment of payments or delinquent debts under these programs.

Additional information regarding this form, routine uses of information, and our programs and systems is available on-line at www.socialsecurity.gov or at your local Social Security office.

Paperwork Reduction Act Statement – This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paper Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 40-50 minutes to read the instructions, gather the facts, and answer the questions. You may send comments on our time estimate about to : SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the complete form.

FORM: SSA L8554-U3