Waiver Of SSI Payment Continued

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Form SSA-263 (09-2016)
Discontinue Prior Editions
Social Security Administration

Page 1 of 2
OMB No. 0960-0783

WAIVER OF SUPPLEMENTAL SECURITY
INCOME PAYMENT CONTINUATION
NAME OF CLAIMANT

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 will have on my monthly
payment amounts.
• I understand that 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)

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

Address of Witness #2
(Number and Street, City, State, Zip Code)

Form SSA-263 (09-2016)

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PRIVACY ACT STATEMENT
Collection and Use of Personal Information
Sections 205(a), 1631(a)(7), and 1631(e)(1)(A) of the Social Security Act, as amended, and CFR 20 §
416.1336(c) authorize us to collect this information. We will use the information you provide to further
document your claim and make a determination regarding your Social Security benefits.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the information
may prevent us from making an accurate and timely decision on any claim filed.
We rarely use the information you supply for any purpose other than what we state above, however, we may
use the information for the administration of our programs including sharing information:
1. 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); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the integrity
and improvement of our programs (e.g., to the Bureau of the Census and to private entities under
contract with us).
A list of when we may share your information with others, called routine uses, is available in our Privacy Act
System of Records Notice 60-0103, entitled Supplemental Security Income Record and Special Veterans
Benefits. Additional information about this and other system of records notices and our programs is available
from our Internet website at www.socialsecurity.gov or at your local Social Security office.
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 incorrect payments or delinquent debts under these
programs.
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.