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 you 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 (SSI)
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 SSI.



You will have to pay back any SSI you may have received beginning



We will send you another letter that explains our decision and what you can do if you
think we are wrong before we take 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 SSI.
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 SSI payments.
You also have the option of applying for Social Security benefits online at
www.socialsecurity.gov. If you have any questions, please get in touch with the Social Security
office shown above.

Manager
Organization Name and Address


FORM SSA-L8050-U3 (08-2009) EF (8-2009)

FORM APPROVED
OMB NO. 0960-0324

SOCIAL SECURITY ADMINISTRATION
Supplemental Security Income
Claim Information
Office Address:



Telephone Number:
Contact Person:
Date:
Social Security Number:

Organization Name and Address


FIELD OFFICE COPY

FORM SSA-L8050-U3 (08-2009) EF (8-2009)

SOCIAL SECURITY ADMINISTRATION
Supplemental Security Income

FORM APPROVED
OMB NO. 0960-0324

Claim Information
Office Address:

Refer To:


Telephone Number:
Contact Person:
Date:
Social Security Number:

The person whose name and address is shown above may be eligible for benefits from you.
We have asked this person to apply for benefits from your organization.
We told this person to apply for benefits from your organization no later
than

.

We need the information about benefits from your organization to decide if this person is eligible
to receive Supplemental Security Income (SSI). In some cases, the person can get a lower
benefit if they apply now but a higher benefit if they apply later. In order to get SSI, the person
whose name is shown above will have to take whatever benefit your organization will give now.
Please fill out Part 3 on the back of this page and return it to us in the enclosed postage paid
envelope.
Thank you for your assistance.
Enclosure

Manager
Organization Name and Address


FORM SSA-L8050-U3 (08-2009) EF (8-2009)

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 information 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

DATE

This information refers to
NAME

Claimant

Other

RELATIONSHIP

SSN

DATE OF BIRTH

SERIAL OR OTHER IDENTIFYING
NUMBER
FROM

TO

FROM

TO

DATES OF MILITARY SERVICE
BRANCH OF SERVICE

DATES OF EMPLOYMENT
PLACE OF EMPLOYMENT

PART 3 TO BE COMPLETED
BY THE
ORGANIZATION

Ineligible

Refused to Apply

Expect Decision

Claim Approved

by

Will Contact Individual

(Date)

SIGNATURE

DATE

TITLE

PHONE NO. (Include Area Code)

Privacy Act and Paperwork Reduction Act Statements
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 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.

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:

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.

(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;
(4) To State agencies providing services to disabled children; and
(5) To facilitate statistical research, audit or investigative activities
necessary to assure the integrity of Social Security programs.

Paperwork Reduction Act Statement - This information
collection meets the requirements
of 44
U.S.C. § Paperwork
3507, as
See
Revised
amended by section 2 of the Paperwork Reduction Act of 1995.
Actdisplay a
You do not need to answer theseReducation
questions unless we
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 THE
COMPLETED FORM TO YOUR LOCAL SOCIAL
SECURITY OFFICE.
To find the nearest office, call
1-800-772-1213 (TTY 1-800-325-0778). Send only comments on
our time estimate above to: SSA, 6401 Security Blvd., Baltimore,
MD 21235-0001.

FORM SSA-L8050-U3 (08-2009) EF (8-2009)

SSA will insert the following revised PRA Statement 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 (OMB) control number. The OMB control number for this
collection is 0960-0324. We estimate that it will take 10 minutes to read the instructions,
gather the facts, and answer the questions. Send only comments relating to our time
estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.