TN 61 (03-05)

A. Procedure - when to use the SSA-L566-U2

Use the SSA-L566-U2 title II application cover notice to transmit a title II application to the applicant for signature, request any needed information/evidence to adjudicate the application and closeout the protective filing.

NOTE: The preprinted notice is also available in Spanish (SSA-L566-U2 SP). Both the English and Spanish versions are available on the Document Processing System (DPS). See SI 00601.040 for the title XVI application cover notices.

B. Procedure - how to complete the notice

1. Identifying information

• Addressee: Enter the applicant’s name and address

• Office Address: Enter the field office (FO) address

• Office Hours: Enter the hours the FO is open to the public

• Telephone Number: Enter the FO telephone number

• Date: Enter the date you issue the notice

• Claim Number: Enter the claimant’s Social Security claim number

2. First paragraph

• Fill-in 1: Enter the date of the interview (mm/dd/yy)

• Fill-in 2: Enter as appropriate: you, or name of applicant

• Fill-in 3: Enter as appropriate: your, name of claimant (possessive)

• Fill-in 4: Enter the appropriate pronoun: your, his, her

• Fill-in 5: Enter as appropriate: you are, he is, she is

3. If we do not hear from you

Fill-in 6: Enter in the space provided either: you are, name of claimant is

a. Block 1

Check block 1 if no previous closeout notice was issued or one was issued, but the protective filing period has expired.

• Fill-in 7: Enter the protective filing closeout date in format (mm/dd/yy) that is 6 months from the date of the notice.

• Fill-in 8: Enter the date of the interview in format (mm/dd/yy). See GN 00204.010A.5., for an illustration of when multiple closeout periods apply.

b. Block 2

Check block 2 if a closeout notice was issued based on a prior protective filing date and the closeout period has not expired.

• Fill-in 9: Enter the protective filing closeout date shown in the prior closeout notice in format (mm/dd/yy).

• Fill-in 10: Enter the protective filing closeout date in format (mm/dd/yy) that is 6 months from the date of the notice.

• Fill-in 11: Enter the date of the application interview in format (mm/dd/yy).

4. Things we need

Place an X in the appropriate block(s) for the information/evidence needed.

• Blocks 1-4

  Enter “for” followed by the individual’s name for whom you are requesting the evidence or leave blank if the notice is sent to the claimant and the proof is for the claimant.

• Block 5-6

  Enter “for” followed by the individual’s name for whom you need the evidence and the year(s) needed. If the notice is addressed to the claimant and the proof is for the claimant, just enter the year(s) needed.

• Block 7

  Enter “for” followed by the name of the individual for whom proof of appointment as legal representative is needed.

• Block 8

  Enter “for” followed by the name of the individual for whom you need a death certificate.

• Block 9

  Enter the type of benefit.

• Block 10

  Enter “for” followed by the individual’s name for whom proof of military service is needed and the years requested. If the claimant is the addressee, just enter the years needed.

• Block 11

  No fill-ins required.

• Block 12

  Enter any information/evidence needed that is not specifically listed in the preprinted blocks.

5. If you have any questions

Fill-in 12: Enter the name of the contact person in the space provided.

C. Procedure - documentation

1. Modernized Claim System (MCS) applications

Annotate the MCS Development Worksheet (DWO1) screen with the SSA-L566-U2 issue date to establish a systems record that the applicant was advised of the protective filing closeout period. Also, retain the file copy of the SSA-L566-U2 notice in the claims folder as a record of the information/evidence requested. Once the application is effectuated, purge the file copy of the SSA-L566-U2.

2. Non-MCS applications

Include the file copy of the SSA-L566-U2 in the claims folder as documentation of the evidence requested and the protective filing closeout date. Once the application is effectuated, purge the file copy of the SSA-L566-U2. See GN 01010.001 for the definitions of effectuate and adjudicate.

NOTE: If the valid application is never received, retain all protective filing documentation, including the SSA-L566-U2 per the appropriate retention period in GN 00204.010F.

D. Exhibit - SSA-L566-U2

Social Security Administration

Application Development

                                                                          Office Address:

                                                                          Office Hours:

                                                                          Telephone Number:

                                                                           Date:

                                                                           Social Security Claim Number:

On     (1)    , we talked with    (2)   about    (3)     possible entitlement to Social Security benefits. We filled out the enclosed application for social security benefits based on     (4)   statements. However, we cannot decide if    (5)    entitled to benefits until you sign the application and give us more information.

What You Need To Do

• Answer any questions circled on the application

• Correct any information that is wrong and sign your initials next to the corrections

• Sign and date the application and any accompanying forms in the space called, “Your Signature”.

• Mail the application, any accompanying forms and the information or evidence checked below to the Social Security office address shown above. A self-addressed envelope is enclosed for your convenience. Add your return address on the envelope and remember to place the correct amount of postage on it.

If We Do Not Hear From You

It is important that you sign the application and return it to us within 10 days of the date of this notice. The sooner we get the signed application, the sooner we can decide if (6 ) eligible. IF WE RECEIVE THE SIGNED APPLICATION AFTER ANY OF THE DATES SHOWN BELOW, YOU MAY LOSE BENEFITS. The block checked below applies to you.

__If we receive the signed application by _____(7)_______, we will use the date we talked to you about possible entitlement to benefits, ______(8)___________, as the filing date.

__If we receive the signed application after ____(9)________, but no later than ___________(10)____________, we will use the date of the application interview, _________(11)_________, as the filing date.

See Next Page

SSA-L566-U2 (03-2005)

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Things We Need

We need the items checked below. You must send us the original documents except as noted below. If you do not have the original, you must send a copy certified by the person who is the custodian of the original record. Do not send copies signed by a notary public. We will return the item(s) to you. We can accept a photocopy of a W-2 form or a tax return (1040, Schedule C, Schedule SE, etc.). Do not delay signing and sending us the enclosed application even if you do not have the records we need.

[ ] Birth Certificate or religious record of age (1)______________

[ ] Marriage Certificate (2)_________________________

[ ] Divorce or Annulment Decree (3)_________________________

[ ] U.S. Passport, Certificate of Citizenship or Naturalization, or current immigration document ____________(4)______

[ ] Withholding statement (Form W-2) for (5)_________________

[ ] Tax return and Schedule SE for ___(6)___________________

[ ] Certificate of Appointment as legal representative for _(7)______

[ ] Death Certificate for (8)________________________________

[ ] Award letter or correspondence concerning (9)______________

[ ] Military service discharge papers (10)______________

[ ] Blank check for direct deposit information (write “VOID” on the front of the check) (11)

[ ] (12) _______________________________________________________

If You Have Any Questions

If you have any questions, you should call, write or visit any Social Security office. If you call or visit our office, please have this letter with you and ask for (12). The telephone number is shown above. We can answer most questions over the phone.

Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly.

Manager

Enclosures:

Application

Envelope

SSA-L566-U2 (3-2005)

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