Statement for Determining Continuing Eligibility for Supplemental Security Income Payment--Adult/Statement for Determining Continuing Eligibility for Supplemental Security Income.....

SOCIAL SECURITY ADMINISTRATION
Instructions for Completing Form SSA-3989-0CR-SM

Why We're
Sending You
The Enclosed
Form

We must regularly review the cases of people who get Supplemental Security Income
(SSI). We check to be sure that each person is still eligible and we are sending the right
amount of money.
As part of your review, we need you to answer the questions on the enclosed form.
It's called Statement For Determining Continuing Eligibility for Supplemental
Security Income Payments, SSA-3989-0CR-SM. If you have a representative payee
(that's someone who receives your SSI payment for you), he or she must complete the
form.
In the enclosed booklet "IMPORTANT FACTS ABOUT SSI" we'll go over some
other important facts. We'll explain:
• Changes you need to report to us.
• Computer matching, Medicaid, transfer of resources and food stamps.

Instructions for Completing the SSA-3989-0CR-SM
How to Complete
Form
SSA-3989-0CR-SM

Here are some things to remember when you are completing the SSA-3989-0CR-SM.
• Use a black ink pen or a #2 pencil.
• Please answer all the questions with one exception. DO NOT ANS\VER Question
15 if you live in:
Alaska
Connecticut
Hawaii
Idaho
Illinois
Indiana
Kansas

Minnesota
Missouri
Nebraska
Nevada
New Hampshire
North Dakota

Northern Mariana Islands
Ohio
Oklahoma
Oregon
Utah
Virginia

• Because you are completing the form for a child, answer questions as if the child
were completing the form.
Because you are completing the form because you are a representative payee; sign
your name in the representative payee space.
Answer "Yes" or "No" questions by marking an "X" inside the "YES" or "NO" boxes.
• Print dates like this: Month/Day/Year, For example, you would print July 4, 2006
like this: 07/04/2006.
•

Show dollar amounts only, do not show $ and do not show dollars and cents. For
example, show $600.55 as 600.

Form SSA-3989-0CR-SM-FST-INST (7-2006)

Pagel

Go 00 To Page 2
!U

• If you answer a question "Yes," also complete all the additional questions. For
example, if you answered Question 7-Has the child spent a full calendar month
in a hospital, nursing home, or other institution? - "Yes," you would write in the
dates the child entered and left.
• A calendar month is all of the days in a month. For example, if the child was
admitted to a hospital on November 23 rd and was discharged on January 4 th , the full
calendar month is December.
For Questions 9 and 10, earned income is money you or if you are a child, your
parenus) receive from work or from owning your own business.
• For Questions II, unearned income is money you or, if you are a child, your
parent(s) receive from a source other than work or self employment, such as interest
on bank accounts, pensions or welfare.
• For Question 13, resources are things that you or, if you are a child, your parent(s)
own and can use to get food or shelter. Resources can be:
• Cash;
• Real property (a house or land); or
• Personal property such as a car, bank accounts, or investments like stocks,
bonds or life insurance.
• Check the address that we have for you. If it's wrong, give us the correct address in
Question 3.
• If you need more space to answer a question, continue your answer in the
REMARKS section on page 11. For example, in Question 4 if 6 people live with
you, enter the name, relationship, date of birth and Social Security Number for 5
persons in Question 4 and the name, relationship, date of birth and Social Security
Number for the 6th person in REMARKS on page II.
If you have any questions or need help completing the form,
call us at 1-800-772-1213.

When to Return The
SSA-3989-0CR-SM

Please return your completed form to us in the enclosed envelope within 30 days
from the date you receive the form.

HWe Don't Hear
From You

Your SSI payments will stop if:
• You do not return the completed SSA-3989-0CR-SM to us;
OR
• You do not contact us to let us know you are having problems completing the
form.
Before we stop payments, we will send you a letter. The letter explains our action
and what to do if you think we are wrong.

Form SSA-3989-0CR-SM-FST-INST (7-2006)

Page 2