Form SSA-263-U2 Waiver of Supplemental Security Income Payment Continuat

Form Approved
OMB No. 0960-0783

SOCIAL SECURITY ADMINISTRATION

WAIVER OF SUPPLEMENTAL SECURITY INCOME PAYMENT CONTINUATION
NAME OF CLAIMANT

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SOCIAL SECURITY NUMBER

This refers to the advance notice of planned action I received on ____________, 20____.
I have been advised of the proposed action (reduction, suspension, or termination) concerning
my Supplemental security income (SSI) payments. I fully understand the results this will have
on my monthly payment amounts.
I understand I have the right to continuation of unreduced payments until a decision is made
on my initial appeal request.
I understand I may request my unreduced payments be reinstated at any time up to the date I
receive a decision on my initial appeal. I understand this includes any retroactive payments
back to the month they were reduced, suspended or terminated.
I understand my rights. I request the Social Security Administration (SSA) take immediate
action to make the change in my payments.
My rights have been explained to me. I voluntarily sign this form.

Your Signature (If you sign with an X, two people must witness below)

Date (Month / Day / Year)

SIGN
HERE
Mailing Address (Number and Street, City, State, Zip Code)

Telephone Number (include area code)

Your statement does not have to be witnessed. If, however, you have signed by marking an (X), two
witnesses must sign below and provide their complete address.
1. Signature of Witness

2. Signature of Witness

Address of Witness #1

Address of Witness #2

(Number and Street, City, State, Zip Code)

(Number and Street, City, State, Zip Code)

Form SSA-263-U2 (xx-xxxx)

Privacy Act Statement
Collection and Use for Personal Information
Sections 205(a) and 1631(e)(A) and (B), and Title 20 CFR 404.1589 and 416.989 of the Social Security Act,
as amended, authorize us to collect this information. The information you provide will be used to further
document your claim and permit a determination about your continuing disability.
The information you furnish on this form is voluntary. However, failure to provide the requested information
could result in a decision based on information already in your file that your period of disability has ceased.
We rarely use the information you supply for any purpose other than for making a determination about your
continuing disability. However, we may use it for the administration and integrity of Social Security programs.
See revised
We may also disclose information to another person or to another agency in accordance with approved
Actto the following:
routine uses, which include but arePrivacy
not limited

Statement below.

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 (e.g., to the Bureau of the Census and private concerns
under contract to Social Security).
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.
A complete list of routine uses for this information is available in our Systems of Records Notices entitled,
Supplemental Security Income Record, 60-0103 and Supplemental Security Income Quality Initial Claims
Review Process System, 60-0212. These notices, additional information regarding this form, and information
regarding our programs and systems, are 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 Paperwork 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 5 minutes to read the instructions, gather the facts, and answer the questions. SEND OR BRING
THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social
Security office through SSA’s website at www.socialsecurity.gov. Offices are also listed under U. S.
Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213
(TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the
completed form.

Form SSA-263-U2 (xx-xxxx)

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a) and 1631(e)(1)(A) and (B), and Title 20 CFR 404.1589 and 416.989 of the
Social Security Act, as amended, authorize us to collect this information. We will use the
information you provide to further document your claim and make a determination on your
disability.
Furnishing us this information is voluntary. However, failing to provide us with the requested
information could prevent us from making an accurate and timely decision on your claim.
We rarely use the information you supply for any purpose other than the reason stated above.
However, we may use the information for the efficient administration and integrity of our
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 us in establishing rights to Social
Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from our 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 our programs (e.g., to the Bureau of the Census and
private entities under contract with us).
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. We use the information from these matching programs to establish or verify a person’s
eligibility for federally funded or administered benefit programs and for repayment of incorrect
payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in our System of Records Notice
entitled Supplemental Security Income Record and Special Veterans Benefits System, 60-0103.
This notice, additional information regarding this form, and information regarding our programs
and systems, are available on-line at www.socialsecurity.gov or at your local Social Security
office.