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SOCIAL SECURITY ADMINISTRATION
Office of Quality Review

«QAOFC_TOLLFREE_NUMBER»

«QAOFC_PHONE_NUMBER»

FAX

Refer to: XXX-XX«CLAIMANTNM»
«CLAIMANTADDR»

Dear «CLAIMANTNM»
«STANDARD_SNO_TEXT» Every month the Social Security Administration’s (SSA), Office of

Quality Review (OQR) examines the claims of Supplemental Security Income (SSI) recipients, in
addition to reviews done by local SSA offices. You are receiving this letter because you receive an
SSI payment. This month we randomly selected you as part of our review, NOT because we have
any special questions about you, nor if you recently completed a review with your local SSA office.

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OQR conducts quality reviews to help the Social Security Administration make sure we pay
everyone the right amount of money.
Your cooperation is very important and helps us make sure you were paid correctly. To make sure
the amount you receive is correct, I, «ANALYST’S NAME», would like YOU to call ME on:
«DATE» at «TIME» at this number, «ANALYST’S PHONE #».
Call me as soon as possible if:
• You have any conflict with this phone appointment time and must reschedule.
• Your phone number, your address, or both are not correct.

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WHAT WILL HAPPEN WHEN YOU CALL
• I will answer questions you have about this review, the Office of Quality Review or SSA.

• I will ask you questions about topics such as, your income, resources, living arrangements,

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and citizenship (if applicable), etc., to ensure the amount you receive in benefits is correct.

• The Social Security law that allows this review is explained in the Privacy Act Statement.
HOW YOU CAN GET READY FOR THE CALL
• You can call SSA at 1-800-772-1213 or your local SSA office to verify the legitimacy of our
review as well as my name and number.

• I have enclosed the INFORMATION NEEDED checklist. Please have the items that are
checked and any others that may apply to you, ready when you call.

• If you would like to have a friend or relative help you during the call, please let that person
know the appointment time, so they are with you.

WHY YOU SHOULD PARTICIPATE
• Your cooperation helps in making certain the benefit amounts paid in this government
program are correct. There is a possibility this review may result in a correction to your
monthly benefit amount.

• If you chose not to participate in this review, your local office may be notified and your
benefits may be suspended.

For more about what the Office of Quality Review does, visit the Social Security Administration’s
official website at www.socialsecurity.gov or www.SSA.gov. In the search box type, “SSA Org
DCARO.” On the results screen, click on SSA Org DCARO and read about OQR in section III
“Functions,” part G “The Office of Quality Review.”
PLEASE RETURN THE ENCLOSED FORM TO ME
Please complete and return the enclosed Acknowledgement Form, with any corrections, along with
the requested items checked below, using the envelope I have provided. You do not need to put a
stamp on the envelope. The Acknowledgement Form is to let me know that you got this letter.
If you prefer, you can go to your local Social Security Office and fax «FAX #» your
Acknowledgement Form and any requested information below or the office can upload your form
and requested information to the SSA Evidence Portal, at no cost to you. If you visit your local
Social Security Office, please take this entire letter to show the technician in the office,
along with any requested items.
If you have any questions, you can reach me between 8 a.m. and 5 p.m. at «ANALYST’S PHONE #».
Sincerely,
Social Insurance Specialist

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Enclosures:
Information Needed
Privacy Act Statement
Acknowledgement Form
Return Envelope

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Thank you for your help and participation.

INFORMATION NEEDED FOR REVIEWING YOUR SSI BENEFITS
Below are topics we will be discussing. Please have the CHECKED ITEMS ready and on hand for the call,
as well as any other items that you think may be needed. This will make the review go faster and smoother.
Please Note: Once your phone appointment is completed, we will advise how to provide any extra
documentation (income, resources, etc.). Failure to submit requested items could result in suspension of
your benefits and delayed future payments.
 Check ALL
SM-3 through SM
A. PERSONAL IDENTIFICATION ITEMS TO ESTABLISH YOUR IDENTITY
 Social Security and Medicare cards for yourself and your spouse, if living with you.
 Record of your birth, birth certificate, or other document showing age for yourself and your spouse, if
your spouse is also eligible for benefits.
 Records of birth of all children (under 18) in the household.
 If foreign born, a naturalization certificate or your Alien Registration card.
B. LIVING ARRANGEMENT INFORMATION

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 Lease agreement or rental contract with your landlord.
 Rent or mortgage receipts for subsidized housing under the Housing and Urban Development Act
(HUD), the Family Home Administration (FMHA), or any other housing assistance.
 If living with anyone other than your spouse or minor children, have estimates of monthly expenses and
household receipts for the last 12 months for mortgage/rent, property insurance, real property tax,
heating fuel, electricity, gas, water, garbage removal, sewer, etc.
 Last tax assessment or tax receipt for any houses, buildings, or land you own.

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C. WORK HISTORY, PENSIONS, AND INCOME
 Union card or union dues book.
 Letters, notice of award, or check stubs for any pensions, or other benefits you or your spouse receive
(other than Social Security).
 Pay slips covering
 Tax return for the last completed year.
 Self-Employment income proof
 Child support
 Unemployment

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D. RESOURCES
 Bank book and/or bank statements covering
for those accounts on which your name appears as
individual or joint owner, or as beneficiary.
 Stock, bonds, promissory notes, etc.
 Burial contract information (deed for plot or crypt) and any information regarding burial funds.
 Ownership or property other than your home.
 Car, truck, or any other vehicle registration or title papers.
 Life insurance and burial insurance policies.
E. INCLUDED FORMS IN THIS LETTER TO BE SIGNED and RETURNED
 SSA-8240, Authorization to Obtain Wage and Employment Information from Payroll Data Providers
 SSA-4641, Authorization For The SSA To Obtain Account Records From A Financial Institution &
Request For Records
F. OTHER

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 1631(d)(1), and 1631(d)(3) of the Social Security Act, as amended, authorize us to collect
this information. We will use the information you provide to make a determination of eligibility for benefits.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information could result in suspension or termination of your benefits.
We rarely use the information you supply us for any purpose other than to make a determination regarding
benefits eligibility. However, we may use the information for the administration of our programs including
sharing information:

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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).

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A complete list of when we may share your information with others, called routine uses, is available in our
Privacy Act System of Records Notice 60-0040, entitled Quality Review System, 60-0042 entitled Quality
Review Case Files, and 60-0057, entitled Quality Evaluation Data Records. Additional information about
this and other system of records notices and our programs are available online at www.socialsecurity.gov or
at your local Social Security office.

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We may share the information you provide to other agencies through computer matching programs.
Matching programs compare our records with records kept by other Federal, State or local government
agencies. We use the information from these programs 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.

SOCIAL SECURITY ADMINISTRATION
Office of Quality Review

«QAOFC_TOLLFREE_NUMBER»

«QAOFC_PHONE_NUMBER»

FAX

ACKNOWLEDGEMENT FORM
PLEASE COMPLETE AND RETURN USING THE ENCLOSED ENVELOPE.
«SNO_RETURN_INSTRUCTION»
RE: Name: «CLAIMANTNM»

Refer to: XXX-XX-

1. I will be available for the telephone call as scheduled.
Yes

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No (If NO, please call me as soon as possible to reschedule. )
2. Your telephone number in our records is: PHONE NUMBER
If the telephone number is incorrect, please provide the
correct number.
__________________________________

Yes

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3. My address is correct as shown:

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No (If no, please provide your correct address.)

4. If you need an interpreter, please specify the language. _______________________________

SSA Reviewer: