OQR Notices - Current Versions

OQR NOTICE CLEARANCE PACKAGE

Office of Quality Review
Initial and Follow-up Evidence Request Letter
March15, 2022
Version 4

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OQR NOTICE CLEARANCE PACKAGE
Notice Clearance Package
Office of Quality Review Initial and Follow-up Evidence
Request Letter
Table of Contents
Background ................................................................................................................... 3
Tab A – Sample Proposed Notices ............................................................................ 6
Sample Notice – Stewardship Initial Evidence Request ............................................ 7
Sample Notice – Stewardship Follow-up Evidence Request .................................... 12
Sample Notice – STAR Initial Evidence Request ..................................................... 17
Tab B – Sample Template ......................................................................................... 22
Tab C – Existing Universal Text Identifiers ........................................................ 33
Tab D – New Universal Text Identifiers with Fill-in Choices ......................... 34

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Background
Improving the language in notices sent to the public, increasing transparency, and
enhancing public service are major goals of the Social Security Administration
(SSA).
OQR carefully reviews our notices to:
•
•
•

Improve readability, clarity, and tone;
Standardize language; and
Update language to reflect current procedures.

The language in this package is one facet of the Office of Quality Review’s (OQR)
ongoing effort to improve the quality of service we provide to the public.
This notice clearance package proposes the creation and inclusion of an evidence
request letter – for OQR use only – into the Document Processing System (DPS).
The Supplemental Security Income (SSI) Stewardship and transaction accuracy
reviews are designed to measure the overall health and monitor the quality of the
SSI program. These reviews determine payment accuracy and compliance with the
law, regulations, Social Security rulings, national Program Operations Manual
System (POMS) instructions, Modernized System Operations Manual (MSOM)
instructions, regional POMS instructions regarding state law and state
supplementation, and other national instructions.
OQR’s field site (FS) analysts frequently request evidence from SSI recipients
during the course of their reviews. Analysts need a consistent and efficient means
of requesting information that adheres to plain language standards.
Additionally, recipients may call or bring letters manually drafted by OQR to field
offices (FO) to authenticate the requests. Because FO staff lack access to the
electronic Quality Assurance (eQA) application OQR uses to store its
documentation, and eQA does not communicate with the Online Retrieval System
(ORS), FO frontline employees may be unable to authenticate the OQR contact and
may misinform the recipient that the letter is fraudulent. The proposed notice will
standardize language used by FS analysts, improve OQR’s visibility to operational
staff, and provide a means by which operational staff can verify the authenticity of
OQR’s requests for evidence.

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OQR NOTICE CLEARANCE PACKAGE
We divided the clearance package into the following sections:
Tab A – Sample showing three examples of final products; including the reading
grade levels for each of the sample notices;
Tab B - Sample template showing the picklist options and new language;
Tab C - A list of existing Universal Text Identifiers (UTI) that will be used by
the template, but the language of the UTI will not change; and
Tab D - Information for new UTIs, including generation criteria, sample
language, and all the fill-in choices. We have included the readinggrade levels for each of the sample UTIs.
When determining the reading-grade levels, we used the simplest fill-in choices and
generic dates, telephone numbers, addresses, and websites. For the notices in Tab
A, we listed two reading-grade levels – the first pertaining to the entire notice and
the second excluding Fraud and Privacy Act language – to demonstrate that the
Fraud and Privacy Act language is complex by nature and increases the level
significantly. As we cannot alter the Fraud and Privacy Act language, we provided
reading-grade levels without it to indicate a more accurate reading-grade level of
the notice.
There are no existing notices to modify; therefore, existing notices are not included.
While Tab A contains samples of completed notices, it should be noted that the
proposed notices contain multiple picklists, which grants the user many variations
for final notice production. As mentioned, Tab B contains a sample template. We
modeled the template after existing templates and identified new UTIs. The new
UTIs are highlighted in yellow. As previously noted, the UTIs listed in Tab C will
not be modified; therefore, we did not include fill-in options. The new UTIs in Tab
D will add 9 new caption UTIs and 52 new paragraph UTIs.
OQR sampled 4,608 Stewardship cases and 4,988 SSI transaction accuracy (STAR)
cases for fiscal year 2019. As OQR currently does not have evidence request notices
generated through DPS, it is difficult to estimate anticipated yearly volume of the
proposed notices.

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Usage
OQR will use the proposed notice to complete SSI Stewardship reviews and STAR.
We will use the notice in conjunction with law, regulations, Social Security rulings,
national POMS instructions, MSOM instructions, regional POMS instructions
regarding state law and state supplementation, and other national policy
instructions. Use and distribution of the notices will be limited to OQR staff. It
should be noted that information collected through use of this notice may be
forwarded to the FO to support corrective action if it is material to payment amount
or eligibility.
Affected notices
The notice will have no impact on any other generated notices.

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Tab A – Sample Proposed Notices

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Sample Notice – Stewardship Initial Evidence Request
Reading Grade Level: 11.2 (8.9 excluding Fraud and Privacy Act
Language)

Social Security Administration
Office of Quality Review: OQR
Request for Information

Social Security
Administration
6401 Security Blvd
Baltimore, MD 21235
Phone: 1-800-555-5555
Fax: 123-456-7890
Date: 12/02/2020
BNC#:12345678910

John Public
1234 Main St
ANYTOWN, MD 12345
Dear Mr. Public
Every month the Social Security Administration asks a few people who get benefit
checks to help us make sure that we pay them the right amount of money. This
month we picked John Public’s name by chance, NOT because we have any special
questions about John Public.
This is a very important letter about keeping your Supplemental Security Income
(SSI). Please read it carefully. If there is anything you do not understand, please get
in touch with us right away.
On 11/15/2020, we talked with you and started a non-medical quality review of
John Public’s SSI benefits.

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We need more information to complete our review. Please send the items listed in
the section titled Information You Must Provide.
Unless otherwise noted, you must send us original or certified documents. Do not
send copies signed by a notary public. If you do not have original documents,
you must send a copy certified by the custodian of the original record. You should
send the items we ask for even if you do not have everything. If you do not have an
item, please call us at 1-888-221-1236.
Information Needed for Reviewing Your SSI Benefits
Please send us the items listed below. The items should cover the time
from 09/2020 through 11/2020.
How to Submit the Information
You can mail us the information we requested directly or you can mail or bring it to
your local Social Security office. Please include a copy of the first page of this letter.
We must receive the information by 01/15/2021. To send us the information directly,
the address is
Attn: John Smith
Social Security Administration
1 Social Security Dr.
ANYTOWN. MD, 12345
We have enclosed a return envelope for your convenience. We provide the address of
your local Social Security office later in this letter.
Information You Must Provide
•

Personal Items
 An original or custodian certified copy of your birth certificate, other birth
record, or other document showing the age for yourself. If your spouse is also
eligible for benefits, proof of age for your spouse.

•

Living Arrangement Information
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 A copy of your mortgage statement or proof of home ownership.
•

OTHER: If John Public is an adult, we need the listed items below
from him, his spouse he lives with if married, and his minor children
he lives with. If he is a minor, we need the listed items below from
him, the parent or stepparent he lives with, and minor siblings he
lives with. The items should cover the time from 09/2021 through
11/2021.
 Form SSA-8510 completed and signed by John Smith.
If We Don't Hear From You
We may ask your local Social Security office for assistance if you do not respond to
our request by 01/15/2021 or contact us to tell us why. Your local Social Security
office will attempt to gain your cooperation with our request. Failure to comply
with your local Social Security office may result in the suspension of John Public’s
benefits. Even if you do not have all of the items, we need to hear from you. We will
help you get anything you do not have. If Social Security stops John Public’s
benefits, John Public could also lose Medicare or Medicaid as well.
Suspect Social Security Fraud?
Please visit http://oig.ssa.gov/r or call the Inspector General's Fraud Hotline at 1800-269-0271 (TTY 1-866-501-2101).
If You Have Questions
•

If you have any questions, please call the reviewer, John Smith, at the Office
of Quality Review at 1-800-555-5555.

Need more help?
1. Visit www.ssa.gov for fast and simple online service.
2. Call us at 1-800-772-1213, weekdays from 8:00 am to 7:00 pm. If you are
deaf or hard of hearing, call TTY 1-800-325-0778. Please mention this
letter when you call.
3. You may also call your local office at 1-800-772-1213.
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Anytown Social Security Administration
123 ABC Street
Anytown, VA 12345
How are we doing? Go to www.ssa.gov/feedback to tell us.

Social Security Administration

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Privacy Act and Paperwork Reduction Act Statements
Sections 205(a), 1611(c)(1), and 1631(d)(1) of the Social Security Act, as amended,
allow us to collect this information. Furnishing us this information is
voluntary. Your local Social Security office will attempt to gain your cooperation
with this request. However, failing to provide all or part of the information may
result in the suspension or termination of benefits.
We will use the information you provide to conduct a quality review and make a
determination of continued eligibility for benefits. We may also share your
information for the following purposes, called routine uses:
•
•

To State agencies for administration of the Medicaid Quality Control system;
and
To a congressional office, in response to an inquiry from that office, made at
the request of the subject of a record.

In addition, we may share this information in accordance with the Privacy Act and
other Federal laws. For example, where authorized, we may use and disclose
information in computer matching programs, in which our records are compared
with other records to establish or verify a person’s eligibility for Federal benefit
programs and for repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records
Notices (SORN) 60-0040, entitled Quality Review System, as published in the
Federal Register (FR) on October 13, 1982, at 47 FR 45606; 60-0042, entitled
Quality Review Case Files, as published in the FR on October 13, 1982, at 47 FR
45607; 60-0057, entitled Quality Evaluation Data Records, as published in the FR
on October 13, 1982, at 47 FR 45615; and 60-0089, entitled Claims Folders System,
as published in the FR on October 31, 2019, at 84 FR 58422. Additional
information, and a full listing of all of our SORNs, is available on our website at
www.ssa.gov/privacy.

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OQR NOTICE CLEARANCE PACKAGE
Sample Notice – Stewardship Follow-up Evidence Request
Reading Grade Level: 11.2 (8.7 excluding Fraud and Privacy Act
Language)

Social Security Administration
Office of Quality Review: OQR
Request for Information

Social Security Administration
6401 Security Blvd
Baltimore, MD 21235
Phone: 1-800-555-5555
Fax: 123-456-7890
Date: 12/02/2020
BNC#:12345678910
John Public
1234 Main St
ANYTOWN, MD 12345
Dear Mr. Public
Second Request
This is a very important letter about keeping your Supplemental Security Income
(SSI). Please read it carefully. If there is anything you do not understand, please get
in touch with us right away.
On 11/15/2020, we sent you a letter requesting information we need to complete our
review. As of the date of this letter, we have not received the information.
We need more information to complete our review. Please send the items listed in
the section titled Information You Must Provide.
Unless otherwise noted, you must send us original or certified documents. Do not
send copies signed by a notary public. If you do not have original documents,
you must send a copy certified by the custodian of the original record. You should
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OQR NOTICE CLEARANCE PACKAGE
send the items we ask for even if you do not have everything. If you do not have an
item, please call us at 1-800-555-5555.
Information Needed for Reviewing Your SSI Benefits
Please send us the items listed below. The items should cover the time
from 09/2020 through 11/2020.
How to Submit the Information
You can mail us the information we requested directly or you can mail or bring it to
your local Social Security office. Please include a copy of the first page of this letter.
We must receive the information by 01/15/2021. To send us the information directly,
the address is
Attn: John Smith
Social Security Administration
1 Social Security Dr.
ANYTOWN. MD, 12345
We have enclosed a return envelope for your convenience. We provide the address of
your local Social Security office later in this letter.
Information You Must Provide
•

Personal Items
 An original or custodian certified copy of your birth certificate, other birth
record, or other document showing the age for yourself. If your spouse is also
eligible for benefits, proof of age for your spouse.

•

Living Arrangement Information
 A copy of your mortgage statement or proof of home ownership.

•

OTHER: If John Public is an adult, we need the listed items below
from him, his spouse he lives with if married, and his minor children
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OQR NOTICE CLEARANCE PACKAGE
he lives with. If he is a minor, we need the listed items below from
him, the parent or stepparent he lives with, and minor siblings he
lives with. The items should cover the time from 09/2021 through
11/2021.
 Form SSA-8510 completed and signed by John Public.
If We Don't Hear From You
We may ask your local Social Security office for assistance if you do not respond to
our request by 01/15/2021 or contact us to tell us why. Your local Social Security
office will attempt to gain your cooperation with our request. Failure to comply
with your local Social Security office may result in the suspension of John Public’s
benefits. Even if you do not have all of the items, we need to hear from you. We will
help you get anything you do not have. If Social Security stops John Public’s
benefits, John Public could also lose Medicare or Medicaid as well.
Suspect Social Security Fraud?
Please visit http://oig.ssa.gov/r or call the Inspector General's Fraud Hotline at 1800-269-0271 (TTY 1-866-501-2101).
If You Have Questions
•

If you have any questions, please call the reviewer, John Smith, at the Office
of Quality Review at 1-800-555-5555.

Need more help?
4. Visit www.ssa.gov for fast and simple online service.
5. Call us at 1-800-772-1213, weekdays from 8:00 am to 7:00 pm. If you are
deaf or hard of hearing, call TTY 1-800-325-0778. Please mention this
letter when you call.
6. You may also call your local office at 1-800-772-1213.
Anytown Social Security Administration
123 ABC Street
Anytown, VA 12345

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How are we doing? Go to www.ssa.gov/feedback to tell us.

Social Security Administration

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Privacy Act and Paperwork Reduction Act Statements
Sections 205(a), 1611(c)(1), and 1631(d)(1) of the Social Security Act, as amended,
allow us to collect this information. Furnishing us this information is
voluntary. Your local Social Security office will attempt to gain your cooperation
with this request. However, failing to provide all or part of the information may
result in the suspension or termination of benefits.
We will use the information you provide to conduct a quality review and make a
determination of continued eligibility for benefits. We may also share your
information for the following purposes, called routine uses:
•
•

To State agencies for administration of the Medicaid Quality Control system;
and
To a congressional office, in response to an inquiry from that office, made at
the request of the subject of a record.

In addition, we may share this information in accordance with the Privacy Act and
other Federal laws. For example, where authorized, we may use and disclose
information in computer matching programs, in which our records are compared
with other records to establish or verify a person’s eligibility for Federal benefit
programs and for repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records
Notices (SORN) 60-0040, entitled Quality Review System, as published in the
Federal Register (FR) on October 13, 1982, at 47 FR 45606; 60-0042, entitled
Quality Review Case Files, as published in the FR on October 13, 1982, at 47 FR
45607; 60-0057, entitled Quality Evaluation Data Records, as published in the FR
on October 13, 1982 at 47 FR 45615; and 60-0089, entitled Claims Folders System,
as published in the FR on October 31, 2019, at 84 FR 58422. Additional
information, and a full listing of all of our SORNs, is available on our website at
www.ssa.gov/privacy.

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Sample Notice – STAR Initial Evidence Request
Reading Grade Level: 11.2 (8.8 excluding Fraud and Privacy Act
Language)

Social Security Administration
Office of Quality Review: OQR
Request for Information

Social Security Administration
6401 Security Blvd
Baltimore, MD 21235
Phone: 1-800-555-5555
Fax: 123-456-7890
Date: 12/02/2020
BNC#:12345678910
John Public
1234 Main St
ANYTOWN, MD 12345
Dear Mr. Public
Every month the Social Security Administration asks a few people who get benefit
checks to help us make sure that we pay them the right amount of money. This
month we picked John Public’s name by chance, NOT because we have any special
questions about John Public.
This is a very important letter about keeping your Supplemental Security Income
(SSI). Please read it carefully. If there is anything you do not understand, please
get in touch with us right away.
On 11/27/2020, we reviewed a recent action on John Public’s SSI case.
We need more information to complete our review. Please send the items listed in
the section titled Information You Must Provide.

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Unless otherwise noted, you must send us original or certified documents. Do not
send copies signed by a notary public. If you do not have original documents,
you must send a copy certified by the custodian of the original record. You should
send the items we ask for even if you do not have everything. If you do not have an
item, please call us at 1-800-555-5555.
Information Needed for Reviewing Your SSI Benefits
Please send us the items listed below. The items should cover the time
from 09/2020 through 11/2020.
How to Submit the Information
You can mail us the information we requested directly or you can mail or bring it to
your local Social Security office. Please include a copy of the first page of this letter.
We must receive the information by 01/15/2021. To send us the information directly,
the address is
Attn: John Smith
Social Security Administration
1 Social Security Dr.
ANYTOWN. MD, 12345
We have enclosed a return envelope for your convenience. We provide the address of
your local Social Security office later in this letter.
Information You Must Provide
•

Personal Items
 An original or custodian certified copy of your birth certificate, other birth
record, or other document showing the age for yourself. If your spouse is also
eligible for benefits, proof of age for your spouse.

•

Living Arrangement Information
 A copy of your mortgage statement or proof of home ownership.
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•

OTHER: If John Public is an adult, we need the listed items below
from him, his spouse he lives with if married, and his minor children
he lives with. If he is a minor, we need the listed items below from
him, the parent or stepparent he lives with, and minor siblings he
lives with. The items should cover the time from 09/2021 through
11/2021.
 Form SSA-8510 completed and signed by John Public.
If We Don't Hear From You
We may ask your local Social Security office for assistance if you do not respond to
our request by 01/15/2021 or contact us to tell us why. Your local Social Security
office will attempt to gain your cooperation with our request. Failure to comply
with your local Social Security office may result in the suspension of John Public’s
benefits. Even if you do not have all of the items, we need to hear from you. We will
help you get anything you do not have. If Social Security stops John Public’s
benefits, John Public could also lose Medicare or Medicaid as well.
Suspect Social Security Fraud?
Please visit http://oig.ssa.gov/r or call the Inspector General's Fraud Hotline at 1800-269-0271 (TTY 1-866-501-2101).
If You Have Questions
•

If you have any questions, please call the reviewer, John Smith, at the Office
of Quality Review at 1-800-555-5555.

Need more help?
7. Visit www.ssa.gov for fast and simple online service.
8. Call us at 1-800-772-1213, weekdays from 8:00 am to 7:00 pm. If you are
deaf or hard of hearing, call TTY 1-800-325-0778. Please mention this
letter when you call.
9. You may also call your local office at 1-800-772-1213.
Anytown Social Security Administration
123 ABC Street
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Anytown, VA 12345
How are we doing? Go to www.ssa.gov/feedback to tell us.

Social Security Administration

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Privacy Act and Paperwork Reduction Act Statements
Sections 205(a), 1611(c)(1), and 1631(d)(1) of the Social Security Act, as amended,
allow us to collect this information. Furnishing us this information is
voluntary. Your local Social Security office will attempt to gain your cooperation
with this request. However, failing to provide all or part of the information may
result in the suspension or termination of benefits.
We will use the information you provide to conduct a quality review and make a
determination of continued eligibility for benefits. We may also share your
information for the following purposes, called routine uses:
•
•

To State agencies for administration of the Medicaid Quality Control system;
and
To a congressional office, in response to an inquiry from that office, made at
the request of the subject of a record.

In addition, we may share this information in accordance with the Privacy Act and
other Federal laws. For example, where authorized, we may use and disclose
information in computer matching programs, in which our records are compared
with other records to establish or verify a person’s eligibility for Federal benefit
programs and for repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records
Notices (SORN) 60-0040, entitled Quality Review System, as published in the
Federal Register (FR) on October 13, 1982, at 47 FR 45606; 60-0042, entitled
Quality Review Case Files, as published in the FR on October 13, 1982, at 47 FR
45607; 60-0057, entitled Quality Evaluation Data Records, as published in the FR
on October 13, 1982 at 47 FR 45615; and 60-0089, entitled Claims Folders System,
as published in the FR on October 31, 2019, at 84 FR 58422. Additional
information, and a full listing of all of our SORNs, is available on our website at
www.ssa.gov/privacy.

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Tab B – Sample Template
(OQRXXX)

Social Security Administration
Office of Quality Review: OQR
(WCPH01)

Request for Information
(SSAH68) Office Address
(SSAH28) Date: [F1]
(SSAH50) BNC#: [F2]
Recipient Name [F1]
Recipient Address [F2]
(SSAH74)
Dear [F1]
Special Notice Optional Mandatory Choice: choose one or none
(SNO016)
As [F1] requested, we will call [F2] within 5 business days of the date of this letter
to read it to [F3].
(SNO015)
We are sending this letter to [F1] in both a standard print version and [F2]. [F3]
will receive them in separate envelopes.
(SNO017)
We are returning [F2] documents with the standard print version of this letter.
None
Mandatory Choice: choose one
Choice 1 of 2 (OQRXXX)
Every month the Social Security Administration asks a few people who get benefit
checks to help us make sure that we pay them the right amount of money. This
month we picked [F1] name by chance, NOT because we have any special questions
about [F2].
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Choice 2 of 2 (INFC52)
Second Request
(ENC002)
This is a very important letter about keeping your Supplemental Security Income
(SSI) [F1]. Please read it carefully. If there is anything you do not understand,
please get in touch with us right away.
Mandatory Choice: choose one
Choice 1 of 3 (OQRXXX)
On [F1], we talked with you and started a non-medical quality review of [F2] SSI
benefits.
Choice 2 of 3 (OQRXXX)
On [F1], we reviewed a recent action on [F2]’s SSI case.
Choice 3 of 3 (OQRXXX)
On [F1], we sent you a letter requesting information we need to complete our
review. As of the date of this letter, we have not received the information.
(OQRXXX)
We need more information to complete our review. Please send the items listed in
the section titled Information You Must Provide.
(OQRXXX)
Unless otherwise noted, you must send us original or certified documents. Do not
send copies signed by a notary public. If you do not have original documents,
you must send a copy certified by the custodian of the original record. You should
send the items we ask for even if you do not have everything. If you do not have an
item, please call us at [F1].
(INFC29)
Information You Must Provide
(OQRXXX)
Please send us the items listed below. The items should cover the time
from [F1] through [F2].
(OQRXXX Caption)
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How to Submit the Information
(OQRXXX)
You can mail us the information we requested directly or you can mail or bring it to
your local Social Security office. Please include a copy of the first page of this letter.
We must receive the information by [F1]. To send us the information directly, the
address is
[F2]
[F3]
[F4]
[F5]
[F6]
We have enclosed a return envelope for your convenience. We provide the address
of your local Social Security office later in this letter.
(INFC29)
Information You Must Provide
(OQRXXX Multiple Choice Category)
Mandatory Choice: choose one or multiple

•

Choice 1 of 5 (OQRXXX)
Personal Items
(OQRXXX Multiple Choice Category conditional on “Personal Identification Items”
selection)
Mandatory Choice: choose one or multiple
Choice 1 of 9 (OQRXXX)
Social Security and Medicare cards for yourself and your spouse, if your spouse is
living with you.
Choice 2 of 9 (OQRXXX)
An original or custodian certified copy of your birth certificate, other birth record, or
other document showing the age for yourself. If your spouse is also eligible for
benefits, proof of age for your spouse.
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OQR NOTICE CLEARANCE PACKAGE

Choice 3 of 9 (OQRXXX)
An original or custodian certified copy of birth certificates of any child under 18 that
lives with you.
Choice 4 of 9 (APT019)
Proof of United States citizenship such as a birth certificate, or, if foreign born, a
naturalization certificate. Or proof of alien status such as an alien registration
receipt card.
Choice 5 of 9 (APT012)
Proof of death such as a death certificate or an SSA-721 (Statement of death by the
funeral director).
Choice 6 of 9 (MAR012)
Original marriage certificate or a custodian certified copy of a public record of
marriage.
Choice 7 of 9 (OQRXXX)
Original divorce decree, custodian certified copy of the divorce decree, or custodian
certified copy of a public record of divorce.
Choice 8 of 9 (APT014)
Proof of military service and period(s) served.
Choice 9 of 9 (AAA006)
(Free text)

•

Choice 2 of 5 (OQRXXX)
Living Arrangement Information
(OQRXXX Multiple Choice Category condition on “Living Arrangement
Information” selection.)
Mandatory Choice: choose one or multiple
Choice 1 of 9 (OQRXXX)
A copy of your lease agreement or rental contract with your property owner.

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OQR NOTICE CLEARANCE PACKAGE
Choice 2 of 9 (OQRXXX)
A copy of your mortgage statement or proof of home ownership.
Choice 3 of 9 (OQRXXX)
Proof that shows the amount of housing assistance. Housing assistance can be
Housing and Urban Development Act (HUD), the Family Home Administration
(FMHA), or other types.
Choice 4 of 9 (OQRXXX)
A copy of your last tax assessment or tax receipt for any houses, buildings, or land
you own.
Choice 5 of 9 (OQRXXX)
Form SSA-8011 completed and signed by [F1].
Choice 6 of 9 (OQRXXX)
Form SSA-795 completed and signed by [F1] regarding living arrangements.
Choice 7 of 9 (OQRXXX)
Form SSA-795 completed and signed by [F1] regarding living arrangements.
Choice 8 of 9 (OQRXXX)
Form SSA-L5061 completed and signed by [F1].
Choice 9 of 9 (AAA006)
(Free text)

•

Choice 3 of 5 (OQRXXX)
INCOME: If [F1] an adult, we need the listed items below from [F2],
[F3] spouse [F4] with if married, and [F5] minor children [F6] with. If
[F7] a minor, we need the listed items below from [F8], the parent or
stepparent [F9] with, and minor siblings [F10] with. The items should
cover the time from [F11] through [F12].
(OQRXXX Multiple Choice Category conditional on “Income” selection.)
Mandatory Choice: choose one or multiple
Choice 1 of 16 (OQRXXX)
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OQR NOTICE CLEARANCE PACKAGE
A printout that shows the amount of Temporary Assistance for Needy Families
(TANF) for each month.
Choice 2 of 16 (OQRXXX)
A printout that shows amount of Refugee Cash Assistance, Bureau of Indian
Affairs, or Disaster Assistance for each month.
Choice 3 of 16 (OQRXXX)
A printout that shows the amount of Adoption, Foster Care, or Kinship
Guardianship assistance for each month.
Choice 4 of 16 (OQRXXX)
A printout that shows the amount for each month of state, local, or tribal
assistance; including unemployment or state disability.
Choice 5 of 16 (OQRXXX)
A printout that shows the amount for each month of private or public assistance the
federal government funds.
Choice 5 of 16 (OQRXXX)
A printout that shows the amount for each month of alimony, spousal, or child
support. The support can be court ordered or voluntary; parent or spouse in or
outside of the household, arrearages, or TANF pass-through.
Choice 6 of 16 (OQRXXX)
Pay stubs or payment history printout.
Choice 7 of 16 (OQRXXX)
A copy of [F1]’s tax return and Schedule SE for [F2]; or all records that show
business income and expenses.
Choice 8 of 16 (OQRXXX)
A printout of the first six months of sick pay [F1] received after [F1] stopped
working. Do not include payments based on [F1]’s contribution or Unearned Sick
Pay. Do not include payments received after the first six months after [F1] stopped
working.
Choice 9 of 16 (OQRXXX)
A printout that shows the amount of Workers’ Compensation for each month.
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OQR NOTICE CLEARANCE PACKAGE

Choice 10 of 16 (OQRXXX)
A printout that shows the amount of unemployment compensation for each month.
Choice 11 of 16 (OQRXXX)
A printout that shows the amount of black lung benefits for each month.
Choice 12 of 16 (OQRXXX)
A printout that shows the amount for each month of pensions. Pensions can be from
the Office of Personnel Management (OPM), Department of Veterans Affairs (VA),
Railroad Retirement Board (RRB), civil service, state, military, or private.
Choice 13 of 16 (OQRXXX)
A printout that shows the amount for each month of dividends, royalties, honoraria,
or rental or lease income.
Choice 14 of 16 (OQRXXX)
A printout that shows the amount for each month of gambling winnings, prizes,
gifts, settlements, or insurance proceeds.
Choice 15 of 16 (OQRXXX)
Form SSA-795 regarding income signed by [F1].
Choice 16 of 16 (AAA006)
(Free text)

•

Choice 4 of 5 (OQRXXX)
RESOURCES: If [F1] an adult, we need the listed items below from [F2],
[F3] spouse [F4] with if married, and [F5] minor children [F6] with. If
[F7] a minor, we need the listed items below from [F8], the parent or
stepparent [F9] with, and minor siblings [F10] with. The items should
cover the time from [F11] through [F12].
(OQRXXX Multiple Choice Category conditional on “Resources” selection)
Mandatory Choice: choose one or multiple
Choice 1 of 12 (OQRXXX)
A copy of trust(s) and any amendments or disbursements.
Choice 2 of 12 (OQRXXX)
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OQR NOTICE CLEARANCE PACKAGE
A copy of car(s), truck(s), or other vehicle(s) registration or title.
Choice 3 of 12 (OQRXXX)
A copy of mortgage statement or proof of ownership of property that is not the home
you live in.
Choice 4 of 12 (OQRXXX)
Proof of value of business equipment you own.
Choice 5 of 12 (OQRXXX)
A copy of the statements of [F1]’s Achieving a Better Life Experience (ABLE)
account. The copies must show deposits, withdrawals, and balances.
Choice 6 of 12 (OQRXXX)
A copy of bank statements for bank accounts you own, jointly own, or are the
beneficiary.
Choice 7 of 12 (OQRXXX)
SSA-795 regarding resources signed by [F1].
Choice 8 of 12 (OQRXXX)
Proof of the value of stock, bonds, mutual funds, promissory notes, loans, property
agreements, etc.
Choice 9 of 12 (OQRXXX)
A copy of life insurance or burial policies [F1] owns.
Choice 10 of 12 (OQRXXX)
Proof of the value of burial funds such as contracts and trusts, burial spaces and
related items such as cemetery lots, crypts, caskets, urns, headstones, markers, etc.
[F1] owns.
Choice 11 of 12 (OQRXXX)
Proof of the value for each month of life estates, un-probated estates, retirement
funds, or mineral rights.
Choice 12 of 12 (AAA006)
(Free text)

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OQR NOTICE CLEARANCE PACKAGE

•

Choice 5 of 5 (OQRXXX)
OTHER: If [F1] an adult, we need the listed items below from [F2], [F3]
spouse [F4] with if married, and [F5] minor children [F6] with. If [F7]
a minor, we need the listed items below from [F8], the parent or
stepparent [F9] with, and minor siblings [F10] with. The items should
cover the time from [F11] through [F12].
(OQRXXX Multiple Choice Category conditional on “Other” selection)
Mandatory Choice: choose one or multiple
Choice 1 of 3 (OQRXXX)
Form SSA-8510 completed and signed by [F1]
Choice 2 of 3 (OQRXXX)
Form SSA-4641 signed by [F1]
Choice 3 of 3 (AAA006)
(Free text)
(CCT006)
We may ask for further information later.
(CAPC40)
If We Don't Hear From You
(OQRXXX)
We may ask your local Social Security office for assistance if you do not respond to
our request by [F1] or contact us to tell us why. Your local Social Security office will
attempt to gain your cooperation with our request. Failure to comply with your
local Social Security office may result in the suspension of John Public’s benefits.
Even if you do not have all of the items, we need to hear from you. We will help you
get anything you do not have. If Social Security stops [F2]’s benefits, [F2] could also
lose Medicare or Medicaid as well.
(MIS117)
Suspect Social Security Fraud?
Please visit http://oig.ssa.gov/r or call the Inspector General's Fraud Hotline at 1800-269-0271 (TTY 1-866-501-2101).
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OQR NOTICE CLEARANCE PACKAGE
(REFC07)
If You Have Questions
(REFXXX)
• If you have any questions, please call the reviewer, [F1], at the Office of
Quality Review at [F2].
(REFXXX-1)
Need more help?
10. Visit www.ssa.gov for fast and simple online service.
11. Call us at 1-800-772-1213, weekdays from 8:00 am to 7:00 pm. If you are
deaf or hard of hearing, call TTY 1-800-325-0778. Please mention this
letter when you call.
12. You may also call your local office at *F1 (Field Office General Inquiry
Line phone number).
*F2 (Office name)
*F3, F4, F5 (Address lines 2-4 separated by commas)
How are we doing? Go to www.ssa.gov/feedback to tell us.

Social Security Administration
Optional (ENC096)
Enclosure(s):
Optional (ENC095)
[F1]
(OQRXXX)
Privacy Act and Paperwork Reduction Act Statements
Sections 205(a), 1611(c)(1), and 1631(d)(1) of the Social Security Act, as amended,
allow us to collect this information. Furnishing us this information is
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OQR NOTICE CLEARANCE PACKAGE
voluntary. Your local Social Security office will attempt to gain your cooperation
with this request. However, failing to provide all or part of the information may
result in the suspension or termination of benefits.
We will use the information you provide to conduct a quality review and make a
determination of continued eligibility for benefits. We may also share your
information for the following purposes, called routine uses:
•
•

To State agencies for administration of the Medicaid Quality Control system;
and
To a congressional office, in response to an inquiry from that office, made at
the request of the subject of a record.

In addition, we may share this information in accordance with the Privacy Act and
other Federal laws. For example, where authorized, we may use and disclose
information in computer matching programs, in which our records are compared
with other records to establish or verify a person’s eligibility for Federal benefit
programs and for repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records
Notices (SORN) 60-0040, entitled Quality Review System, as published in the
Federal Register (FR) on October 13, 1982, at 47 FR 45606; 60-0042, entitled
Quality Review Case Files, as published in the FR on October 13, 1982, at 47 FR
45607; 60-0057, entitled Quality Evaluation Data Records, as published in the FR
on October 13, 1982 at 47 FR 45615; and 60-0089, entitled Claims Folders System,
as published in the FR on October 31, 2019, at 84 FR 58422. Additional
information, and a full listing of all of our SORNs, is available on our website at
www.ssa.gov/privacy.

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Tab C – Existing Universal Text Identifiers
The proposed quality review notice will use the following existing universal text
indicators without modifying language or fill-in selections:
WCPH01: Request for Information
SSAH68: Office Address
SSAH28: Date
SSAH50: Refer to - heading
SSAH74: Salutation
SNO015: SNO Braille, data CD, audio CD, or large print
SNO016: SNO follow up phone call
SNO017: SNO returning documents with standard print letter
INFC52: New Caption (Second Request)
ENC002: Keeping Your SSI
INFC29: Info you must provide - Caption
APT019: Proof of citizenship
APT012: Proof of death
MAR012: Marriage certificate or raised seal copy
APT014: Proof of military service
AAA006: Additional Information Needed
CCT006: More Information
CAPC40: If We Don't Hear From You – Caption
REFC07: CAPTION - If You Have Questions
MIS117: Suspect Social Security Fraud? Caption & Paragraph
ENC096: Enclosure(s)
ENC095: Additional enclosure(s)

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Tab D – New Universal Text Identifiers with Fill-in
Choices
The following are new universal text identifiers (UTI). We have included all fill-in
selection options and the reading-grade level of each UTI. When determining the
reading-grade levels, we used the simplest fill-in choices and generic dates,
telephone numbers, addresses, and websites. We highlighted new UTI language.
Rationale and reading-grade level are in blue. It should be noted that the readinggrade level of individual UTIs may be higher without the context of other UTIs.
The overall reading-grade level of a completed notice may be lower than an
individual UTI.
(OQRXXX-1)

Social Security Administration
Office of Quality Review: OQR
New header for OQR.
Reading grade level: 0 (Mandatory)
(OQRXXX-2)
Every month the Social Security Administration asks a few people who get benefit
checks to help us make sure that we pay them the right amount of money. This
month we picked [F1] name by chance, NOT because we have any special questions
about [F2].
[F1] – your, his, her, or Recipient name (possessive)
[F2] – you, him, her, or Recipient name
New language regarding QR case selection.
Reading grade level: 11.4 (Mandatory)
(OQRXXX-4)
On [F1], we talked with you and started a non-medical quality review of [F2] SSI
benefits.
[F1] – Date selection – MM/DD/YYYY
[F2] – your, his, her, or Recipient’s name (possessive)
Lead-in statement to identify initial Stewardship request.
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OQR NOTICE CLEARANCE PACKAGE
Reading grade level: 12.9 (Optional)
(OQRXXX-5)
On [F1], we reviewed a recent action on [F2] SSI case.
[F1] – Date selection – MM/DD/YYYY
[F2] – your, his, her, or Recipient’s name (possessive)
New language to identify STAR initial requests.
Reading grade level: 9.2 (Optional)
(OQRXXX-6)
On [F1], we sent you a letter requesting information we need to complete our
review. As of the date of this letter, we have not received the information.
[F1] – Date selection – MM/DD/YYYY
New language used with follow-up request notices for both Stewardship and STAR
QRs.
Reading grade level: 9.1 (Optional)
(OQRXXX-7)
We need more information to complete our review. Please send the items listed in
the section titled Information You Must Provide.
New language for the QR process.
Reading grade level: 7.6 (Mandatory)
(OQRXXX-8)
Unless otherwise noted, you must send us original or certified documents. Do not
send copies signed by a notary public. If you do not have original documents,
you must send a copy certified by the custodian of the original record. You should
send the items we ask for even if you do not have everything. If you do not have an
item, please call us at [F1].
[F1] User phone number
New language for the QR process.
Reading grade level: 10.2 (Mandatory)
(INFC29 Caption)
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OQR NOTICE CLEARANCE PACKAGE
Information You Must Provide
New caption to indicate the requested information.
Reading grade level: 9.5 (Mandatory)
(INFXXX)
Please send us the items listed below. The items should cover the time
from [F1] through [F2].
[F1] – Date selection – MM/YYYY
[F2] – Date selection – MM/YYYY
New language to identify the QR sample period.
Reading grade level: 8.6 (Mandatory)
(INFCXX Caption)
How To Submit the Information
New caption to identify how to submit information to OQR.
Reading grade level: 0 (Mandatory)
(INFXXX)
You can mail us the information we requested directly or you can mail or bring it to
your local Social Security office. Please include a copy of the first page of this letter.
We must receive the information by [F1]. To send us the information directly, the
address is
[F2]
[F3]
[F4]
[F5]
[F6]
We have enclosed a return envelope for your convenience. We provide the address of
your local Social Security Office later in this letter.
[F1] – Date selection – MM/DD/YYYY
[F2] – User mailing address 1
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OQR NOTICE CLEARANCE PACKAGE
[F3] – User mailing address 2
[F4] – User mailing address 3
[F5] – User mailing address 4
[F6] – User mailing address 5
New language tailored to OQR.
Reading grade level: 8.2 (Mandatory)

•

(INFCXX-13 Caption)
Personal Items
New Caption to identify needed identification items.
Reading grade level: 0 (Optional)
(INFXXX)
 Social Security and Medicare card for [F1].

[F1] – Recipient name
New language of information OQR may need to request to complete the QR.
Reading grade level: 9.6 (Optional)
(INFXXX)
 Social Security and Medicare card for [F1] spouse.
[F1] – Recipient name possessive
New language of information OQR may need to request to complete the QR.
Reading grade level: 8.8 (Optional)
(INFXXX)
 An original or custodian certified copy of the birth certificate, other birth
record, or other document that shows the date of birth of [F1].
[F1] – Recipient name
New language of information OQR may need to request to complete the QR.
Reading grade level: 14.4 (Optional)
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OQR NOTICE CLEARANCE PACKAGE

(INFXXX)
 An original or custodian certified copy of the birth certificate, other birth
record, or other document that shows the date of birth of [F1] spouse.
[F1] – your, Recipient name possessive
New language of information OQR may need to request to complete the QR.
Reading grade level: 14.5 (Optional)
(INFXXX)
 An original or custodian certified copy of birth certificates of any of [F1]
siblings under 18 who live with [F2].
[F1] – your, Recipient name possessive
[F2] – you, him, her, Recipient name
New language of information OQR may need to request to complete the QR.
Reading grade level: 13.9 (Optional)
(INFXXX)
 Original divorce decree, custodian certified copy of the divorce decree, or
custodian certified copy of a public record of divorce.
New language of information OQR may need to request to complete the QR.
Reading grade level: 16.9 (Optional)

•

(INFCXX Caption)
Living Arrangement Information
New caption to identify living arrangement information needed for the QR.
Reading grade level: 0 (Optional)
(INFXXX)
 A copy of the lease agreement or rental contract with the property owner
where [F1].
[F1] – you live, Recipient name lives
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New language of information OQR may need to request to complete the QR.
Reading grade level: 9.0 (Optional)
(INFXXX-20)
 A copy of the mortgage statement or proof of home ownership where [F1].
[F1] – you live, Recipient name lives
New language of information OQR may need to request to complete the QR.
Reading grade level: 7.5 (Optional)
(INFXXX)
 Proof that shows the amount of housing assistance where [F1]. Housing
assistance can be Housing and Urban Development Act (HUD), the Family
Home Administration (FMHA), or other types.
[F1] – you live, Recipient name lives
New language of information OQR may need to request to complete the QR.
Reading grade level: 9.9 (Optional)
(INFXXX)
 A copy of the last tax assessment or tax receipt for any houses, buildings, or
land [F1].
[F1] – you own, Recipient name owns
New language of information OQR may need to request to complete the QR.
Reading grade level: 8.5 (Optional)
(INFXXX)
 A copy of the last tax assessment or tax receipt for any houses, buildings, or
land [F1] spouse owns.
[F1] – your, Recipient name possessive
New language of information OQR may need to request to complete the QR.
Reading grade level: 8.7 (Optional)
(INFXXX)
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OQR NOTICE CLEARANCE PACKAGE
 Form SSA-8011 completed and signed by [F1].
[F1] – Name of person signing form
New language of information OQR may need to request to complete the QR.
Reading grade level: 5.2 (Optional)
(INFXXX)
 Form SSA-795 regarding living arrangements completed and signed by [F1].
[F1] – Name of person signing form
New language of information OQR may need to request to complete the QR.
Reading grade level: 9.0 (Optional)
(INFXXX)
 Form SSA-L5061 completed and signed by [F1].
[F1] – Name of person signing form
New language of information OQR may need to request to complete the QR.
Reading grade level: 2.2 (Optional)

•

(INFXXX)
INCOME: If [F1] an adult, we need the listed items below from [F2],
[F3] spouse [F4] with if married, and [F5] minor children [F6] with. If
[F7] a minor, we need the listed items below from [F8], the parent or
stepparent [F9] with, and minor siblings [F10] with. The items should
cover the time from [F11] through [F12].
[F1-1] – you are
[F1-2] - [Recipient first and last name] is
[F1-3] – he is
[F1-4] – she is
[F2-1] – you
[F2-2] – him
[F2-3] – her
[F3-1] – your
[F3-2] – his
[F3-3] – her
[F4-1] – you live
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OQR NOTICE CLEARANCE PACKAGE
[F4-2] – he lives
[F4-3] – she lives
[F5-1] – your
[F5-2] – his
[F5-3] – her
[F6-1] – you live
[F6-2] – he lives
[F6-3] – she lives
[F7-1] – you are
[F7-2] – he is
[F7-3] – she is
[F8-1] – you
[F8-2] – him
[F8-3] – her
[F9-1] – you live
[F9-2] – he lives
[F9-3] – she lives
[F10-1] – you live
[F10-2] – he lives
[F10-2] – she lives
[F11] - Date selection – MM/DD/YYYY
[F12] – Date selection – MM/DD/YYYY

New language of information OQR may need to request to complete the QR.
Reading grade level: 10.0 (Optional)
(INFXXX)
 A printout that shows the amount of Temporary Assistance for Needy
Families (TANF) for each month.
New language of information OQR may need to request to complete the QR.
Reading grade level: 9.8 (Optional)
(INFXXX)
 A printout that shows amount of Refugee Cash Assistance, Bureau of Indian
Affairs, or Disaster Assistance for each month.
New language of information OQR may need to request to complete the QR.
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OQR NOTICE CLEARANCE PACKAGE
Reading grade level: 12.3 (Optional)
(INFXXX)
 A printout that shows the amount of adoption, foster care, or kinship
guardianship assistance for each month.
New language of information OQR may need to request to complete the QR.
Reading grade level: 10.4 (Optional)
(INFXXX)
 A printout that shows the amount for each month of state, local, or tribal
assistance, including unemployment or state disability.
New language of information OQR may need to request to complete the QR.
Reading grade level: 12.8 (Optional)
(INFXXX)
 A printout that shows the amount for each month of private or public
assistance the federal government funds.
New language of information OQR may need to request to complete the QR.
Reading grade level: 9.7 (Optional)
(INFXXX)
 A printout that shows the amount for each month of alimony, spousal, or
child support. The support can be court ordered or voluntary; parent or
spouse in or outside of the household, arrearages, or TANF pass-through.
New language of information OQR may need to request to complete the QR.
Reading grade level: 7.4 (Optional)
(INFXXX)
 Pay stubs or payment history printout.
New language of information OQR may need to request to complete the QR.
Reading grade level: 6.4 (Optional)
(INFXXX)
 A copy of the tax return and Schedule SE for [F1], or all records that show
business income and expenses.
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[F1] – Year selection – YYYY
New language of information OQR may need to request to complete the QR.
Reading grade level: 7.0 (Optional)
(INFXXX)
 A printout of the first six months of sick pay received after work stopped. Do
not include payments based on contributions or unearned sick pay. Do not
include payments received after the first six months after work stopped.
New language of information OQR may need to request to complete the QR.
Reading grade level: 5.4 (Optional)
(INFXXX)
 A printout that shows the amount of workers’ compensation for each month.
New language of information OQR may need to request to complete the QR.
Reading grade level: 6.7 (Optional)
(INFXXX)
 A printout that shows the amount of unemployment compensation for each
month.
New language of information OQR may need to request to complete the QR.
Reading grade level: 8.7 (Optional)
(INFXXX)
 A printout that shows the amount of black lung benefits for each month.
New language of information OQR may need to request to complete the QR.
Reading grade level: 4.9 (Optional)
(INFXXX)
 A printout that shows the amount for each month of pensions. Pensions can
be from the Office of Personnel Management (OPM), Department of Veterans
Affairs (VA), Railroad Retirement Board (RRB), civil service, state, military,
or private.

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OQR NOTICE CLEARANCE PACKAGE
New language of information OQR may need to request to complete the QR.
Reading grade level: 11.4 (Optional)
(INFXXX)
 A printout that shows the amount for each month of dividends, royalties,
honoraria, or rental or lease income.
New language of information OQR may need to request to complete the QR.
Reading grade level: 11.0 (Optional)
(INFXXX)
 A printout that shows the amount for each month of gambling winnings,
prizes, gifts, settlements, or insurance proceeds.
New language of information OQR may need to request to complete the QR.
Reading grade level: 9.7 (Optional)
(INFXXX)
 Form SSA-795 regarding income signed by [F1].
[F1] – Name of person signing the form
New language of information OQR may need to request to complete the QR.
Reading grade level: 3.7 (Optional)

•

(INFXXX)
RESOURCES: If [F1] an adult, we need the listed items below from
[F2], [F3] spouse [F4] with if married, and [F5] minor children [F6]
with. If [F7] a minor, we need the listed items below from [F8], the
parent or step-parent [F9] with, and minor siblings [F10] with. The
items should cover the time from [F11] through [F12].

Fill-in Options:
[F1-1] – you are
[F1-2] - [Recipient first and last name] is
[F1-3] – he is
[F1-4] – she is
[F2-1] – you
[F2-2] – him
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OQR NOTICE CLEARANCE PACKAGE
[F2-3] – her
[F3-1] – your
[F3-2] – his
[F3-3] – her
[F4-1] – you live
[F4-2] – he lives
[F4-3] – she lives
[F5-1] – your
[F5-2] – his
[F5-3] – her
[F6-1] – you live
[F6-2] – he lives
[F6-3] – she lives
[F7-1] – you are
[F7-2] – he is
[F7-3] – she is
[F8-1] – you
[F8-2] – him
[F8-3] – her
[F9-1] – you live
[F9-2] – he lives
[F9-3] – she lives
[F10-1] – you live
[F10-2] – he lives
[F10-2] – she lives
[F11] - Date selection – MM/DD/YYYY
[F12] – Date selection – MM/DD/YYYY
New caption to identify resources needed to complete the QR.
Reading grade level: 10.0 (Optional)
(INFXXX)
 A copy of any trusts and any amendments or disbursements.
New language of information OQR may need to request to complete the QR.
Reading grade level: 9.5 (Optional)
(INFXXX)
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OQR NOTICE CLEARANCE PACKAGE
 A copy of any cars, trucks, or other vehicles’ registration or title.
New language of information OQR may need to request to complete the QR.
Reading grade level: 9.7 (Optional)
(INFXXX)
 A copy of the mortgage statement or proof of ownership of any property that
[F1] does not live in.
[F1] – Recipient first and last name
New language of information OQR may need to request to complete the QR.
Reading grade level: 9.9 (Optional)
(INFXXX)
 Proof of the value of any owned business equipment.
New language of information OQR may need to request to complete the QR.
Reading grade level: 7.5 (Optional)
(INFXXX)
 A copy of the Achieving a Better Life Experience (ABLE) account statements.
The copies must show deposits, withdrawals, and balances.
New language of information OQR may need to request to complete the QR.
Reading grade level: 9.5 (Optional)
(INFXXX)
 A copy of bank statements for any solely or jointly owned bank accounts.
New language of information OQR may need to request to complete the QR.
Reading grade level: 7.6 (Optional)
(INFXXX)
 Form SSA-795 regarding resources signed by [F1].
[F1] Name of person signing the form
New language of information OQR may need to request to complete the QR.
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Reading grade level: 3.7 (Optional)
(INFXXX)
 Proof of the value of stock, bonds, mutual funds, promissory notes, loans, and
property agreements.
New language of information OQR may need to request to complete the QR.
Reading grade level: 9.1 (Optional)
(INFXXX)
 A copy of life insurance or burial policies.
New language of information OQR may need to request to complete the QR.
Reading grade level: 9.6 (Optional)
(INFXXX)
 Proof of the value of burial funds. Burial funds include contracts and trusts,
burial spaces and related items including cemetery lots, crypts, caskets, urns,
headstones, and markers.
New language of information OQR may need to request to complete the QR.
Reading grade level: 10.2 (Optional)
(INFXXX)
 Proof of the value for each month of life estates, un-probated estates,
retirement funds, or mineral rights.
New language of information OQR may need to request to complete the QR.
Reading grade level: 10.4 (Optional)

•

(INFXXX Caption)
OTHER: If [F1] an adult, we need the listed items below from [F2], [F3]
spouse [F4] with if married, and [F5] minor children [F6] with. If [F7]
a minor, we need the listed items below from [F8], the parent or
stepparent [F9] with, and minor siblings [F10] with. The items should
cover the time from [F11] through [F12].
[F1-1] – you are
[F1-2] - [Recipient first and last name] is
[F1-3] – he is
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[F1-4] – she is
[F2-1] – you
[F2-2] – him
[F2-3] – her
[F3-1] – your
[F3-2] – his
[F3-3] – her
[F4-1] – you live
[F4-2] – he lives
[F4-3] – she lives
[F5-1] – your
[F5-2] – his
[F5-3] – her
[F6-1] – you live
[F6-2] – he lives
[F6-3] – she lives
[F7-1] – you are
[F7-2] – he is
[F7-3] – she is
[F8-1] – you
[F8-2] – him
[F8-3] – her
[F9-1] – you live
[F9-2] – he lives
[F9-3] – she lives
[F10-1] – you live
[F10-2] – he lives
[F10-2] – she lives
[F11] - Date selection – MM/DD/YYYY
[F12] – Date selection – MM/DD/YYYY
New caption to identify other information needed to complete the QR.
Reading grade level: 10.0 (Optional)
(INFXXX)
 Form SSA-8510 completed and signed by [F1].
[F1] – Name of person signing the form

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New language of information OQR may need to request to complete the QR.
Reading grade level: 2.2 (Optional)
(INFXXX)
 Form SSA-4641 signed by [F1].
[F1] – Name of person signing the form
New language of information OQR may need to request to complete the QR.
Reading grade level: 0.0 (Optional)
(OQRXXX-58)
We may ask your local Social Security office for assistance if you do not respond to
our request by [F1] or contact us to tell us why. Your local Social Security office will
attempt to gain your cooperation with our request. Failure to comply with your
local Social Security office may result in the suspension of [F2]’s benefits. Even if
you do not have all of the items, we need to hear from you. We will help you get
anything you do not have. If Social Security stops [F3]’s benefits, [F4] could also lose
Medicare or Medicaid as well.
[F1] – Date selection – MM/DD/YYYY
[F2] – Recipient first and last name
[F3] – Recipient first and last name
[F4] – Recipient first and last name
New language informing the individual/payee that OQR may ask for FO assistance
to complete the QR.
Reading grade level: 9.5 (Mandatory)
(REFXXX)
• If you have any questions, please call the reviewer, [F1], at the Office of
Quality Review at [F2].
(REFXXX-1)
Need more help?
13. Visit www.ssa.gov for fast and simple online service.

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14. Call us at 1-800-772-1213, weekdays from 8:00 am to 7:00 pm. If you are
deaf or hard of hearing, call TTY 1-800-325-0778. Please mention this
letter when you call.
15. You may also call your local office at *F1 (Field Office General Inquiry
Line phone number).
*F2 (Office name)
*F3, F4, F5 (Address lines 2-4 separated by commas)
How are we doing? Go to www.ssa.gov/feedback to tell us.
Fill-ins:
F1 – FO Phone contact info – General Inquiry Line
F2 – FO Address Line 1
F3 – FO Address Line 2
F4 – FO Address Line 3
F5 – FO Address Line 4

New language tailored to OQR to provide contact information for questions.
Reading grade level: 11.4 (Mandatory)
(OQRXXX-60)
Social Security is open to the public Monday through Friday. The hours are 9:00AM
to 4:00PM.
New language of informing the individual/payee of FO public hours of operation.
Reading grade level: 7.4 (Mandatory)
(ACTXXX)
Privacy Act and Paperwork Reduction Act Statements
Sections 205(a), 1611(c)(1), and 1631(d)(1) of the Social Security Act, as amended,
allow us to collect this information. Furnishing us this information is
voluntary. Your local Social Security office will attempt to gain your cooperation
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OQR NOTICE CLEARANCE PACKAGE
with this request. However, failing to provide all or part of the information may
result in the suspension or termination of benefits.
We will use the information you provide to conduct a quality review and make a
determination of continued eligibility for benefits. We may also share your
information for the following purposes, called routine uses:
•
•

To State agencies for administration of the Medicaid Quality Control system;
and
To a congressional office, in response to an inquiry from that office, made at
the request of the subject of a record.

In addition, we may share this information in accordance with the Privacy Act and
other Federal laws. For example, where authorized, we may use and disclose
information in computer matching programs, in which our records are compared
with other records to establish or verify a person’s eligibility for Federal benefit
programs and for repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records
Notices (SORN) 60-0040, entitled Quality Review System, as published in the
Federal Register (FR) on October 13, 1982, at 47 FR 45606; 60-0042, entitled
Quality Review Case Files, as published in the FR on October 13, 1982, at 47 FR
45607; 60-0057, entitled Quality Evaluation Data Records, as published in the FR
on October 13, 1982 at 47 FR 45615; and 60-0089, entitled Claims Folders System,
as published in the FR on October 31, 2019, at 84 FR 58422. Additional
information, and a full listing of all of our SORNs, is available on our website at
www.ssa.gov/privacy.
Required language tailored to reference OQR.
Reading grade level: 15.9 (Mandatory)

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