Form SSA-1023 MMA Outreach Mailer Insert

Request an application today by
completing the information on
the back of this card.
Privacy Act Statement
Social Security can collect the information on this form under section 205 of the Social Security Act. We need
this to follow up on your application for Extra Help. Giving us this information is voluntary. However, without it
we may not be able to properly help you. Neither the Social Security Administration nor its contractor will use
the information for any other purpose.
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 1 minute to read the
instructions and complete the form. 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.

First Name

Last Name

Street Address

Apt #

City

State

Social Security Number
—

Zip Code

Phone Number

—

—

—

Please use black or blue ink. Use one block for each letter.
Form SSA-1023-SM (03-2008)

OMB No. 0960-NEW