Form SSA-L8050-U3 Supplemental Securrity Income Claim Information Notice

SOCIAL SECURITY ADMINISTRATION
Supplemental Security Income

FORM APPROVED
OMB NO. 0960-0324

Claim Information
Office Address:

Telephone Number:

Contact Person:

Date:

Social Security Number:

We are writing to let you know that yoti' may be able to receive a benefit from the organization
shown at the bottom of this page. We need to know if you can receive benefits from this
organization so that we can make a decision about your Supplemental Security Income (SST)
payments.

..

You must apply for and take any action needed to receive benefits from this organization by
If you do not take action by this date:

• You will not be eligible for SS!.
• You will have to pay back any SSI you may have received beginning
• We will senu you another leiter that explains our decision and what you can do if you

think we are wrong before we talce any further action on your claim.

If you want to receive SSI payments, you must apply for any benefits you can get now. In some
cases, you can get a lower benefit if you apply now but a higher benefit if you apply later. You
have to take whatever benefit the organization will give you now to receive SS!.
Please take or mail the enclosed form to the organization shown below right away. When the
organization returns the form to us, we will make a decision about your SST payments.
If you have any questions, please get in touch with the Social Security office shown above.

Manager
Organization Name and Address

FORM SSA-U1050-U3 (12-1991) EF (11·2001)

PART 1 TO BE COMPLETED
BY THE
INDIVIDUAL

Please let me know how to file a claim for a pension,
annuity, or benefit from your organization.
I hereby authorize the Social Security Administration to
release the information shown below. I also authorize your
organization to release any informati,on to the Social
Security Administration about any claim I have filed or
intend to file with your organization.
SIGNATURE

PART 2­
TO BE COMPLETED
BY THE SOCIAL
SECURITY
ADMINISTRATION

This information refers to

D

NAME

Claimant

D

Other

RELATIONSHIP

DATE OF BIRTH

SSN

SERIAL OR OTHER IDENTIFYING
NUMBER

FROM

TO

FROM

TO

DATES OF MILITARY SERVICE
BRANCH OF SERVICE

DATES OF EMPLOYMENT
PLACE OF EMPLOYMENT

PART 3TO BE COMPLETED
BY THE
ORGANIZATION

o

Ineligible

o

o

Expect Decision
Claim Approved
by _______________________

Refused to Apply

0

Will Contact Individual

D

(Date)

SIGNATURE

DATE

TITLE

PHONE NO. (Include Area Code)

Privacy Act and Paperwork Reduction Act Statements
Tile Social Security Act, sections 1611 (e)(2) and 1612 (a)(2)(B),
allows us to collect the facts we ask for on this form. You do not have
to answer this request. However. if you do not give us the facts we
have requested. we may not be able to make Supplemental Security
Income payments to this person.
Sometimes we share the information on this form with another
government agency, or person to administer the Social Security
program or programs requiring coordination with the Social Security
Administration (SSA).
We may also use the information y~u give us when we match records
hy computer. Matching programs ~ompare our records with those of
other Federal. State, or local government agencies. Many agencies
may use matching programs to find- or prove that a person qualifies for

See revised

henefits paid by the Federal government. The law allows us to
do this even if you do not agree to it.
Privacy Act and

Paperwork
Explanations about these and other reasons
why information you
are availahle inAct
Social
provide us may be used or given out Reduction
Security offices. If you want 10 learn more about this. contact
Statements below.
any Social Security office.
This information collection meets the clearance requirements of
44 U.S.C. § 3507, as amended by section 2 of the Paperwork
Reduction Act of 1995. You are not required to answer these
questions unless' we display a valid Office of Management and
Budget control !lumber. We estimate that it will take you about
10 minutes to E,ead the instructions, gather the necessary facts,
and answer the questions.

FORM SSA·L8050·U3 (12·1991 J EF (11·2001)

Privacy Act Notice:
Sections 1611(e)(2) and 1612(a)(2)(B) of the Social Security Act, as amended, authorize
us to collect this information. This information is needed to determine if you qualify for
benefits from the listed organization and a possible adjustment to your Supplemental
Security Income (SSI). The information you provide on this form is voluntary, however,
failure to provide the requested information may adversely impact your SSI benefits.
We rarely use the information you supply for any purpose other than for establishing
benefit eligibility. 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 Veteran Affairs);

(3)

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

(5)

To State agencies providing services to disabled children; and

(6)

To facilitate statistical research, audit or investigative activities necessary
to assure the integrity 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 and 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 System of Records
Notices 60-0103. The notice, additional information regarding this form, and information
regarding our programs and systems, are available on-line at www.ssa.gov or at your
local Social Security office.

The following revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
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 10
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. The office is 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.