Current Confirmation Letter for Interview

SOCIAL SECURITY ADMINISTRATION
Office of Quality Review
«QAOFC_TOLLFREE_NUMBER»

«QAOFC_PHONE_NUMBER»

FAX

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

Dear «CLAIMANTNM»

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«STANDARD_SNO_TEXT»Every month the Social Security Administration
asks a few people who get benefit checks to help us make sure that we pay
everyone the right amount of money. This month we picked your name by
chance, NOT because we have any special questions about you. To make
sure the amount you receive is correct, I would like you to telephone me toll
free at my office on:
WHAT WILL HAPPEN WHEN YOU CALL

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• I will identify myself as shown on the bottom of this letter.
• I will ask you questions about your benefits. The Social Security law
that allows this review is explained in the enclosed Privacy Act
Information letter.

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HOW YOU CAN GET READY FOR THE CALL
• I have enclosed a page that shows the kind of papers you should
have when you call. Please have the items that are checked and
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 when you will call.
PLEASE RETURN THE ENCLOSED FORM TO ME
Please fill in the blank spaces on the enclosed form and mail it back to me in
the envelope I have provided. You do not need to put a stamp on the
envelope. The form is to let me know that you got this letter.

If you have any questions, you can reach me at my office between 8 a.m.
and 5 p.m. My telephone number is phone number. Thank you for your
help.
Sincerely,

,
Social Insurance Specialist

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Enclosures:
Information Needed
Privacy Act Notice
Acknowledgement Letter
Return Envelope

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INFORMATION NEEDED FOR REVIEWING YOUR SSI BENEFITS
Please have the ITEMS CHECKED below on hand for review. If you think that any other
items that are not checked are important for your benefits, please have them on hand also.
Check All SM-3 through SM
A. PERSONAL IDENTIFICATION ITEMS
Social Security and Medicare cards for yourself and your spouse, if your spouse is 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/subsidies.
If living with anyone other than your spouse or minor children, have estimates of food
expenses and monthly 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.
C. WORK HISTORY, PENSIONS, AND INCOME

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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
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. OTHER

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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.

RE: Name: «CLAIMANTNM»

Refer to: XXX-XX-

PLEASE COMPLETE AND RETURN THIS FORM TO
ME«SNO_RETURN_INSTRUCTION»
1. I will be available for the call as scheduled.
Yes
No (IF No, please phone me toll free phone numbers to set a
better time)
PHONE NUMBER

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2. Your telephone number in our records
is:
If the telephone number is incorrect,
please provide the correct number.
3. My address is correct as shown:

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Yes

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

4. If you need an interpreter, please specify the
language.
5. Signature
SSA Reviewer:

Date

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