GN 00201: Program - Related Claims Practices
TN 21 (01-08)
A. Introduction
As SSA expands its electronic processing, SSA has adopted alternative signature methods to the traditional pen-and-ink or “wet” signature in order to implement a fully electronic application process which eliminates the need to retain paper applications. These instructions discuss three approved signature alternatives/signature proxies, which are attestation, click and sign, and a witnessed signature.
Signature Proxy has been implemented as follows:
June 21, 2004— Applications filed by claimants for Title II (including the lump sum death payment), Title XVI applications and amendments, and pre-effectuation review contacts.
November 20, 2004— Signature proxy became applicable for redeterminations processed on the Modernized Supplemental Security Income Claims System (MSSICS), applications filed on behalf of minor children by natural and adoptive parents, Medicare only applications, and claims taken in Foreign Service Posts and VARO in Manila that have access to the Modernized Claims System (MCS).
June 25, 2005 — Signature proxy became available for Title II amendments filed by claimants, and the signature proxy interviewer’s script was included in the MCS path.
November 19, 2005 — Signature proxy is applicable for Representative payee applications taken on the Representative Payee System (RPS) for individual and organizational payees for Title II and Title XVI claimants (see GN 00502.110 for the policy and procedures for the use of signature proxy for representative payee applications taken on RPS).
November 19, 2005 — Applications filed on behalf of claimants by third parties who are proper applicants such as a court-appointed representative for a legally incompetent claimant can be signed via attestation or witnessed signature. See “Proper Applicant Title II” (GN 00204.003) and “Proper Applicant Title XVI” (SI 00601.012).
March 15, 2006 — Signature proxy is applicable for specifically approved SSA forms. The first two forms approved for this expansion of signature proxy are forms SSA-820 (Work Activity Report – Self Employed Person) and SSA-821 (Work Activity Report – Employee). Signature proxy for these forms only applies when these forms are taken in connection with claims at the initial or appeal levels. If the forms are taken with claims at the initial or appeal levels, claims attestation applies. If the forms are taken separately, then form attestation must apply. See GN 00201.015F.6. and eDG Guide reference DI 81010.120 for policy and procedures for the use of signature proxy for Forms SSA-820/821.
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July 12, 2006 — Signature proxy is expanded to the following forms when taken in connection with an initial claim:
SSA-21 (Supplement to Claim of Person Outside the United States)
SSA-150 (Modified Benefit Formula Questionnaire)
SSA-308 (Modified Benefit Formula Questionnaire-Foreign Pension)
SSA-7163 (Questionnaire About Employment or Self-Employment Outside the United States)
SSA-7163A (Supplemental Statement Regarding Farming Activities of Person Living Outside the U.S.A.)
April 21, 2012 — Claimants who complete the Internet Adult Disability Report on their own behalf are given the option to electronically sign Form SSA-827 (Authorization to Disclose Information to the Social Security Administration) via SSA’s eAuthorization click and sign process. See DI 11005.056 for policy and procedures for the electronic signature process for the SSA-827.)
August 11, 2012 – SSA’s eAuthorization click and sign process is expanded to claimants who complete the Internet Disability Report-Appeal on their own behalf.
December 1, 2012 – Adult claimants (age 18 or older) signing Form SSA-827 on their own behalf have the option to sign the form using SSA’s attestation process during a field office disability interview (for example, in office, video conference, and teleclaim interviews), or via face-to-face or telephone contact with an SSA or DDS employee.
August 3, 2013 – Child claimants (under age 18) signing Form SSA-827 on their own behalf, or individuals with the authority to sign on behalf of a child claimant have the option to sign the form using SSA’s attestation process during a field office interview (for example, in office, video conference, and teleclaim interviews), or via face-to-face or telephone contact with an SSA or DDS employee.
June 22, 2015 — Technician may attest forms SSA-821-BK, Work Activity Report - Employee and SSA-820-BK, Work Activity Report – Self Employment when conducting work continuing disability reviews (CDR) in eWork. See DI 10505.035 and DI 10510.025 for policy and procedures for the use of signature proxy for Forms SSA-820/821.
NOTE: The signature alternatives do not apply to cases that are excluded from being taken and processed in SSA's automated claims systems. Therefore, for MCS, MSSICS, and RPS exclusion cases which cannot be taken on the system, the paper application and forms must always be retained.
B. Definitions
1. Attestations/Form attestations
a. Attestation
Attestation is the action taken by a SSA employee of confirming and annotating on MCS, MSSICS, or RPS the proper applicant’s:
Intent to file or complete a claims-related form,
Affirmation under penalty of perjury that the information provided is correct, and
Agreement to sign the application, amendment, redetermination, or SSA forms approved for attestation that are completed with the claim/amendment.
NOTE: See DI 11005.056 for information about the attestation process for Form SSA-827 (Authorization to Disclose Information to the Social Security Administration).
b. Form attestation
Form Attestation is the action taken by a SSA employee when obtaining a signature on a SSA form that is completed in conjunction with a claim/amendment, but after the claim/amendment has been signed, including attestation.
2. Click and sign
Click and sign is the action taken by the claimant of clicking the “SIGN NOW” button at the conclusion of the online application representing his or her affirmation under penalty of perjury that the information provided is correct, and intent to electronically sign and submit application data to SSA.
NOTE: See DI 11005.056 for information about the click and sign process for Form SSA-827 (Authorization to Disclose Information to the Social Security Administration).
3. Witnessed signature
Witnessed Signature is the action taken by a SSA employee of annotating MCS, MSSICS, or RPS that he or she received a paper application, amendment, redetermination, or other form with a pen-and-ink signature and the proper applicant has not previously signed the application, amendment, redetermination, or other form by attestation. A pen-and-ink signature includes a mark or thumbprint made by the applicant.
C. Policy — attestation
For Title II and Title XVI in-person applications and teleclaims, Title II and Title XVI amendments, Title XVI redeterminations, and other forms completed as part of the claims/appeals process, the interviewer confirms the proper applicant’s intent to file and sign the application and other forms, provides and reviews the penalty clause notice, and attests to the proper applicant’s intent to sign the application and other forms by annotating SSA records (i.e., MCS/MSSICS/RPS). The act of attesting to these facts is documentation of the proper applicant’s signature and is deemed equivalent to a signature.
D. Policy — click and sign
For claimants who complete online applications (i.e., Internet Claim Application, also known as iClaim), a click of the “SIGN NOW” button at the end of the application represents their intent to file an application, affirm under penalty of perjury that the information is correct, and electronically sign and submit their application data to SSA. The application is considered signed when submitted. At this time, however, Internet filing can only be done in the United States.
NOTE: See DI 11005.056 for information about the click and sign process for Form SSA-827 (Authorization to Disclose Information to the Social Security Administration).
E. Policy — witnessed signature
When a paper application/printout (including an amendment, redetermination, or other form approved for signature proxy) is filed with a pen-and-ink signature and the proper applicant has not previously signed the application and/or other form via attestation, a SSA employee annotates MCS, MSSICS, or RPS by receipting the ATTEST issue to indicate that he or she received the paper application/printout and/or other form with a pen-and-ink signature on it. The electronic annotation is deemed equivalent to the pen-and-ink signature.
F. Procedure — attestation/form attestation — in-person and telephone interviews
1. Interviewer responsibilities
Interviewers are required to do the following:
Inform proper applicants that SSA no longer requires a pen-and-ink signature. Explain to proper applicants that the interviewer will confirm the proper applicant’s intent to file, affirmation under penalty of perjury that the information provided is correct, and agreement to sign the application for benefits, amendment, redetermination, and/or other related forms approved for signature proxy. The interviewer's annotation of the same in SSA records constitutes a signed application/valid legal signature.
Read the scripted language, which can be found in the MSSICS and MCS initial claims path and is shown in GN 00201.015F.2. and GN 00201.015F.3. during the interview process. Refer to GN 00201.015M. to view printable versions of the script in English and Spanish.
Confirm the proper applicant’s intent to file and sign the application for benefits, amendment, redetermination, or other forms approved for signature proxy.
Complete the application or other forms approved for signature proxy.
Review the penalty clause notice.
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Provide the proper applicant with a copy of the cover notice with the penalty clause language.
NOTE: In MSSICS, the cover notices can be printed on the DPRN screen. In addition, the receipts for signature proxy, i.e., attestation and witnessed signature, will also be printed in MSSICS.
IMPORTANT: You must print the cover notice before receipting in the claim. If you receipt in the claim before indicating on the DPRN screen to print the cover notice, the ability to print the cover notice from the DPRN screen is eliminated and the Document Processing Systesm (DPS) will have to be used to prepare the notice. However, do not print a cover notice with the Title XVI summary unless evidence is also being requested.
The modified Title II claim receipt can be printed on the DW01 in MCS and may be used in lieu of the DPS attestation notice in limited situations, e.g., evidence is not needed. If evidence is outstanding or the claim is excluded from signature proxy, the MCS receipt should not be used.
If evidence is required, continue to use DPS where the notice is under the category, “Cover Letter” and is also available in Spanish. When the notice is prepared in DPS, click on the “Print and Send to ORS” on the toolbar to ensure that a copy of the notice is sent to the Online Retrieval System (ORS). For an exhibit of the attestation cover notice see (GN 00201.015J).
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Print the MCS claim and give it to the proper applicant, or mail it if a teleclaim was taken for his or her review and retention, along with the reporting responsibilities and claim receipt. Advise the proper applicant to review the material and contact SSA within 10 days if he or she needs to make any corrections. Any corrections received postadjudicatively will be handled following current procedures.
A mirror image of the claim will be placed on ORS.
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In Title XVI signature proxy cases, provide claimants with an Application Summary for Supplemental Security Income, Amendments to Application Summary for Supplemental Security Income, or Review Statement Summary for Supplemental Security Income (PERC) as applicable. None of the summaries (also referred to as Summary Statements) include a signature block. Each summary is one document and includes a summary of the claimant's statements, penalty of perjury language, reporting responsibilities, and receipt. For deferred and abbreviated applications the summaries do not include reporting responsibilities, and the amendment summary only includes statements about changes to information essential to eligibility and/or payment.
REMEMBER: Unless evidence is also being requested, there is no need to include the signature proxy cover notice with the summary.
Title XVI applications, summary statements and amendments, along with representative payee applications taken in RPS “must be printed” to be stored in ORS.
However, when a pen-and-ink signature is required, continue to request the application, review statement (PERC), and amendments (which have the signature block) by selecting the appropriate option and print without attest from the DPRN screen.
Annotate MCS or MSSICS per GN 00201.015F.4. (See GN 00502.110C. for annotating the RPS.)
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Adjudicate the application if all required proofs have been received and all determinations have been completed. If additional information/evidence is required, discuss what is needed with the proper applicant and include the evidence paragraph in the attestation cover notice (see GN 00201.015J.). For Title XVI, also include the evidence closeout paragraph. Title XVI follow-up evidence requests should be made using the SSA-L8009-U3 (Supplemental Security Income, Important Information (IC).
For Title II, see GN 00301.150 for follow-up procedures when evidence is requested. Also, see GN 00301.286 for recording evidence electronically and also retaining evidentiary documents, when required.
REMINDER: Effective 11/19/05 whenever evidence or documents cannot be retained electronically, the Paper Indicator Screen (PIIP) should be used. The PIIP screen will be presented in all MCS initial claims situations and in MSSICS initial claims and post eligibility situations, including all redeterminations, limited issues, and stand alone post eligibility events. The indicator does not provide information describing the paper artifact or its location.
NOTE: Effective 10/14/05, it is no longer necessary to complete a Modernized Development Worksheet to alert the processing center that a Listing Code applies to the case. The Processing Center Action Control System (PCACS) will now create an Electronic Control Record (ECR) when a listing is received in PCACS and there is no paper associated with the listing. The ECR is a placeholder in PCACS that allows transactions (such as Listing Code updates) to be processed for accounts that have no paper folder associated with them.
2. Attestation - script for in-person interviews
a. Start of the interview
“During this interview, we will ask you questions that will be used to process your/or name of claimant's (application/amendment/ redetermination/name of form) for (benefits/Medicare). At the end of the interview, we will ask you to confirm the truthfulness of your answers under penalty of perjury and we will record your response. You should be aware that you can be held legally responsible for giving us false information.”
b. End of the interview — review of printed output
“Here is a printed copy of the information that will be used to process your/or name of claimant's (application/amendment/redetermination/name of form). Please review all the information carefully and let us know right away if anything needs to be corrected OR if any of the information changes.”
c. Obtain proper applicant’s affirmation of intent to file and understanding of penalty clause
“Do you understand that the information you gave us and examined will be used to process your/or name of claimant's (application /amendment/redetermination/name of form) for (benefits/Medicare)? Do you declare under penalty of perjury that this information is true and correct to the best of your knowledge?”
3. Attestation - script for telephone interviews
a. Start of the interview
“During this interview, we will ask you questions that will be used to process your/or name of claimant's (application /amendment/ redetermination/name of form) for (benefits/Medicare). At the end of the interview, we will ask you to confirm the truthfulness of your answers under penalty of perjury and we will record your response. You should be aware that you can be held legally responsible for giving us false information.”
b. End of the interview — review of printed output
“You will receive a printed copy of the information being used to process your/or name of claimant's (application/amendment/redetermination/name of form) to retain for your records. Do you understand that you must review all of this information carefully and let us know right away if anything needs to be corrected OR if any of the information changes?”
c. Interviewer's script — obtain proper applicant's affirmation of intent to file and understanding of penalty clause
“Do you understand that the information you have provided will be used to process your/or name of claimant's (application /amendment/ redetermination/name of form)? Do you declare under penalty of perjury that this information is true and correct to the best of your knowledge?”
4. Documentation requirements
a. Title II
For Title II claims and amendments, the ATTEST issue automatically propagates to the DW01. For Title II Form Attestations, the interviewer creates the ATTEST issue on the DW01. Document that all requirements for attestation have been met by typing the receipt date for the ATTEST issue in MCS.
When the issue “ATTEST” is displayed in the Issue field and a date is entered in the receipt field, MCS propagates the interviewer’s three position office code, a space, up to six letters of the interviewer’s last name, a comma, and the first initial to the Remarks field. The comma following the last name is a floating comma. If the last name contains fewer than six characters, the comma should immediately follow the last character of the last name (e.g., 216 Cox, N). The ATTEST issue(s) and interviewer’s name will be retained electronically and deemed equivalent to the signature for the application or amendment.
b. Title XVI
For Title XVI claims, amendments, and redeterminations, the ATTEST issue automatically propagates to the DW01. Document that all requirements for attestation have been met by typing the receipt date for the ATTEST issue in MSSICS.
When the issue, “ATTEST” is displayed in the Issue field and a date is entered in the receipt field, MSSICS propagates the interviewer’s three position office code, a space, up to six letters of the last name, a comma, and the first initial in the Remarks field. The comma following the last name is a floating comma. If the last name contains fewer than six characters, the comma should immediately follow the last character of the last name (e.g., Cox, N). The ATTEST issue(s) and interviewer's name will be retained electronically and deemed equivalent to the signature for the application or amendment.
5. Redeterminations (RZ)
Use attestation as the signature for redeterminations processed on MSSICS beginning November 20, 2004. Also, if a recipient or payee insists on signing the redetermination with a pen-and-ink signature, follow the witnessed signature procedures once the signed redetermination is received. See the procedures in SI 02305.003 when processing redeterminations using alternative signature methods.
6. Designated forms approved for signature proxy
The designated forms approved for signature proxy are as follows:
SSA-21 (Supplement to Claim of Person Outside the United States)
SSA-150 (Modified Benefit Formula Questionnaire)
SSA-308 (Modified Benefit Formula Questionnaire-Foreign Pension)
SSA-820 (Work Activity Report—Self Employed Person)
SSA-821 (Work Activity Report—Employee)
SSA-7163 (Questionnaire About Employment or Self-Employment Outside the United States)
SSA-7163A (Supplemental Statement Regarding Farming Activities of Person Living Outside the U.S.A.)
SSA-827 (Authorization to Disclose Information to the Social Security Administration (SSA)) NOTE: Effective April 2012, signature proxy for Form SSA-827 is not available to all claimants. See DI 11005.056 for information about the eAuthorization signature processes for Form SSA-827.
IMPORTANT: The SSA-21 must be signed (or attested to) by both a number holder (NH) and his or her spouse if both are claiming benefits. Therefore, when a single SSA-21 is completed with information about a NH and a spouse who are both claiming benefits, MCS development worksheets (DW01) for both claimants must be annotated to show the SSA-21 as an ISSUE for required attestation documentation. Also, the signature block of the SSA-21 must be annotated “ATTEST,” along with the interviewer’s name and office code.
a. Completed as part of the initial claim
When the above forms are completed as part of the initial claim:
Signature proxy should be used for these forms when they are taken in connection with initial claims.
Use standard attestation scripts shown in GN 00201.015F.2. and GN 00201.015F.3. during the interview process.
Annotate the “Signature Page” on the forms with “ATTEST,” along with the interviewer's name and office code.
All forms attested to as part of the initial interview are part of the claims(s) attestation. Provide the applicant with a copy of the form as part of the application materials detailed in GN 00201.015F.2.b. and GN 00201.015F.3.b.
The “ATTEST” issue on the MCS or MSSICS development worksheet (DW01) and the interviewer’s name will be retained electronically and deemed equivalent to the signature for the form taken with the application.
b. Completed after initial claim
When forms are completed after the initial claim has been taken and attested to:
Complete the form shown in GN 00201.015F.6. and initiate form attestation for the form.
Annotate the “Signature Page” on the form with “ATTEST,” along with the interviewer’s name and office code.
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Use DPS to generate the form attestation cover letter (see GN 00201.015L. for the notice exhibit). The notice is combined with the Attestation Cover Letter and is under the “Cover Letters” menu on DPS; the notice is also available in Spanish. Give or mail the applicant a copy of the form.
NOTE: See DI 81010.120, Creating Electronic Disability Collect System (EDCS) Cases, for instructions on uploading the SSA-820/821 to the electronic folder (EF).
Show receipt of the form on the Development Worksheet (DW01). On the next line of the DW01, create an issue of “ATTEST” for the form attestation. Show the same receipt date. After entering the screen, MSSICS/MCS will generate the user’s three position office code, followed by the first six letters of the last name and first initial. The ATTEST issue and the interviewer’s name are retained electronically and are deemed equivalent to a pen-and-ink signature.
For all forms where form attestation is applicable, ensure the following:
The DW01 is annotated with a protected ATTEST issue, and
Issuance of an attestation cover letter is documented in the Online Retrieval System,
The SSA-820/821 marked “ATTEST,” is filed, uploaded or faxed into the official folder.
The SSA-21, SSA-150, SSA-308, SSA-7163 and SSA-7163A marked “ATTEST” are filed, uploaded or faxed into the paperless file.
IMPORTANT: Refer to the Electronic Disability Guide (eDG)—DI 81010.120 for operational procedures specific to updating the Certified Electronic Folder.
G. Procedure — click and sign
1. Internet filing process
The Internet filing process requires that claimants and/or interviewers do the following:
Claimants who file for benefits on the Internet do not print and sign a paper application and return it to SSA. Instead, after completing the online application and reading the penalty clause language, claimants click the “SIGN NOW” button which transmits the information on the Internet application to SSA.
Identify electronically signed applications on pending Workload Management Information (WMI) Listings and propagate the data into MCS daily using existing procedures for propagating data that are contained in GN 00204.055.
Obtain necessary proofs and any other development following the process as outlined in GN 00204.055.
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Receipt in the ATTEST issue with a date.
NOTE: The word “Internet” propagates to the appropriate application, i.e., DIB, RIB, Aux Spouse on the MCS DW01 to indicate that an Internet claim was filed using “click and sign.”
NOTE: Some additional forms approved for signature proxy (e.g., SSA-821) which are needed for an Internet application can be signed using form attestation. The interviewer will add an ATTEST issue specific to that form on the development worksheet.
After downloading the online application data from iClaim to MCS, ORS is automatically updated with a copy of the Internet application summary as submitted by the claimant. This secures the integrity of the information the beneficiary provided on the Internet application.
Adjudicate the application if all required proofs have been received and all determinations have been completed.
NOTE: See DI 11005.056 for information about the click and sign process for Form SSA-827 (Authorization to Disclose Information to the Social Security Administration).
2. Internet application jurisdiction
Jurisdiction of Internet claims (i.e., iClaim) IS automatically assigned to Workload Support Units (WSUs) based on terminal digits unless a WSU exclusion applies (e.g., disability alleged, proof of age or citizenship not proven, etc.). If a WSU exclusion applies, jurisdiction is assigned to the servicing field office (FO). WMI jurisdiction is also assigned in this manner. Management will review and assign all signed Internet applications (electronic and wet-signed) on a daily basis.
H. Procedure — witnessed signature
1. When witnessed signature may apply
Two situations where witnessed signature may apply are:
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Proper applicant insists on signing with pen-and-ink.
NOTE: For teleclaims, mail the application for signature using the Title II cover notice in GN 00204.014 or the Title XVI cover notice in SI 00601.040 which includes protective filing closeout language.
REMEMBER: Until we receive a signed application from the proper applicant, the date the application was started serves as a protective filing date which must be closed out in accordance with instructions in GN 00204.012 or SI 00601.037.
A paper signed application from a proper applicant is received that was not generated from MCS, MSSICS, or RPS. For example, the proper applicant printed and completed a SSA-1, retirement application from SSA's list of forms on the website.
2. Signed application received
When a completed application summary or paper application is received signed by the proper applicant with a pen-and-ink signature (i.e., the application was not signed via attestation), the interviewer will:
Return the signed paper application to the proper applicant using the witnessed signature cover notice in GN 00201.015K. which informs him or her that the paper application will not be retained by SSA;
Provide the proper applicant with a copy of the application summary, reporting responsibilities and claim receipt;
Annotate MCS, MSSICS, or RPS by receipting the ATTEST issue to indicate that the application was signed with a pen-and-ink signature (no additional remark is required); and
Adjudicate the application if all required proofs have been received and all determinations have been completed. If additional evidence is needed, follow the procedures in GN 00301.150 and SI 00601.100 for obtaining Title II and Title XVI evidence respectively. Also, see GN 00301.286 for recording evidence electronically and retaining evidentiary documents, when required.
I. Procedure — amendments
When the proper applicant makes changes or corrections to the application summary which require an amendment, do the following:
1. Title II
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If the Title II claim is received with changes or the proper applicant calls to report changes which are substantive and require a signature, follow the attestation procedures in GN 00201.015F.
NOTE: Effective June 25, 2005 MCS associates the ATTEST issue with the related amendment (similar to the association of ATTEST with the application). Text which explains the condition that caused the amendment is generated in the REMARKS field of the APPAMD issue on the MCS DW01 screen. This process is currently designed for critical elements only. Store the amendments in ORS by using the print facility and the automated propagation of the interviewer’s name.
Print the application amendment and provide it to the proper applicant using the attestation notice in GN 00201.015J.
Document the ATTEST issue in accordance with GN 00201.015F.4.a.
2. Title XVI
If the Title XVI claim or Application Summary for Supplemental Security Income is received with changes or the proper applicant calls to report changes which are substantive and require a signature, follow the attestation procedures in GN 00201.015F.
Print the application amendment or Amendments to Application Summary for Supplemental Security Income and provide it to the proper applicant using the attestation notice in GN 00201.015J.
Document the ATTEST issue in accordance with GN 00201.015F.4.b.
NOTE: If the proper applicant does not want to use attestation as the signature for the amendment, obtain a pen-and-ink signature on the amendment by selecting the appropriate option and print without attest from the DPRN screen. Once the amendment is signed, annotate MSSICS by receipting the ATTEST issue to indicate that the amendment was signed with a pen-and-ink signature. Return the amendment to the proper applicant using the witnessed signature cover notice in GN 00201.015K. which is also available in Spanish.
J. Exhibit - attestation cover notice - (instructions on completing the notice follow the exhibit)
Social Security Administration
Supplemental Security Income
Important Information
Office Address:
Date:
Social Security Number:
On (1) , we talked with you and completed an application for (2) . We stored the application information electronically in our records and are enclosing a summary of your statements.
What You Need to Do
Review the application information to ensure we recorded your statements correctly.
If you agree with all your statements, you may retain the information for your records.
If you disagree with any of your statements, you should contact us within 10 days after the date of this notice to let us know.
IMPORTANT REMINDER:
Penalty of Perjury
You declared under penalty of perjury that you examined all the information on this form and it is true and correct to the best of your knowledge. You were told that you could be liable under law for providing false information.
What We Need (optional paragraph)
We need the items listed below to decide if ___ (3) _______ can receive benefits. We must see the original document(s) or a certified copy of the item(s). We cannot accept photocopies except for tax returns. We will return the item(s) to you.
Please bring or mail these items to us right away. The sooner we receive the item(s), the sooner we can decide if ___ (4) _______ eligible.
APT040 Proof of age
APT041 Proof of marriage
APT042 Proof of divorce or annulment
APT012 Proof of death
APT015 Proof of tax/wage withholding
APT020 Proof of income
APT021 Proof of resources
APT097 Evidence—citizenship/residence status
APT010 Proof needed with disability claim
DID024 Bank name, account number, and routing number for direct deposit
INF011 Request for life insurance policies
INF006 Request for pension records
INF007 Request for pay stubs
INF008 Request for self-employment records
INF009 Request for unemployment compensation records
INF010 Request for workers' compensation award letter
INF025 SSA-827 Authorization
Additional Information
If We Do Not Hear From You (SSI only paragraph and required if evidence paragraph used)
If you do not respond to our request for information or evidence or contact us by (5) , we may deny your application for SSI. Even if you don't have all of the information, we need to hear from you. We will help you get anything you do not have.
Information about Medicaid (SSI only)
In many States, filing for SSI means you are also filing for Medicaid. If we deny your SSI application, you cannot get Medicaid based on SSI.
If You Have Any Questions
If you have any questions, you may call, write or visit any Social Security office. If you call or visit, please have this letter with you and ask for (6) . The telephone number is (7) . 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
Enclosure(s):
Application or summary
Form(s) (8) __
Fill-in 1
Date of Interview (mm/dd/yyyy)
Fill-in 2
Choice 1 — Supplemental Security Income (SSI)
Choice 2 — Social Security Benefits
Choice 3 — Social Security and SSI
Choice 4 — Medicare only
Fill-in 3
Enter as appropriate: you, name of claimant
Fill-in 4
Enter as appropriate: you are, name of claimant is
Fill-in 5
30 days after the date of the notice (mm/dd/yyyy)
Fill-in 6
Claims representative’s (CR) name
Fill-in 7
CR’s telephone number
Fill-in 8
Form SSA- (Enter the form number(s))
1. Completing the DPS attestation cover notice
After selecting the appropriate Title II or Title XVI header, and English or Spanish text, complete the DPS attestation cover notice as follows:
a. Identifying information
Addressee
Enter the proper applicant’s name and address information.
Office Address
Enter the FO or teleservice center address.
Date
Enter the date you issue the notice.
Social Security Number
Enter the claimant’s SSN.
b. First paragraph
Fill-in 1
Enter the date of the interview.
Fill-in 2
Enter the type of claim.
c. What you need to do
No fill-ins are required for the text under this caption.
d. Important reminder
This caption is mandatory.
e. Penalty of perjury
This caption is mandatory.
f. Perjury language
No fill-ins are required for the text.
g. What we need (optional paragraph for Title II or Title XVI when evidence is being requested)
Select the evidence being requested.
h. If we do not hear from you (SSI only paragraph and required if evidence paragraph is used)
Enter the evidence closeout paragraph which is mandatory for Title XVI when evidence is requested.
NOTE: Fill-in (5) __: Enter a date that is 30 days after the date of the notice.
For Title II evidence requests, apply the normal evidence follow-up and closeout procedures as outlined in GN 00301.150.
i. Information about Medicaid (SSI only)
The language under this caption is mandatory for Title XVI claims.
j. If you have any questions
Fill-in (6) Enter the name of the claims representative (CR) in the space provided.
Fill-in (7) Enter the telephone number of the CR in the space provided.
k. Enclosure(s)
Type the words “Application or summary as appropriate.”
Fill-in (8) Enter the form number(s) in the space provided.
l. Disposition of the notice
For in-person claims, the attestation cover notice will accompany the application or summary and/or form(s) that is given to the proper applicant for his or her records, along with the claim receipt.
For teleclaims, the attestation cover notice will be mailed to the proper applicant with the application or summary and/or form(s) for his or her retention, along with the claim receipt.
K. Exhibit - witnessed signature cover notice – (instructions for completing the notice follow the exhibit)
Social Security Administration
Important Information
Office Address:
Date:
Social Security Number:
We are returning the attached application to you for your records.
We stored the application information electronically so there is no reason for us to retain a paper copy of the application.
IMPORTANT REMINDER:
Penalty of Perjury
You declared under penalty of perjury that you examined all the information on this form and it is true and correct to the best of your knowledge. You were told that you could be liable under law for providing false information.
If You Have Any Questions
If you have any questions, you may call, write or visit any Social Security office. If you call or visit, please have this letter with you and ask for (1) . The telephone number is (2) . 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
Enclosure(s):
Application summary
Fill-in 1:
Claims representative's (CR) name
Fill-in 2:
The CR's telephone number
1. Completing the witnessed signature cover notice
After selecting the appropriate Title II or Title XVI header, and English or Spanish text, complete the witnessed signature cover notice as follows:
a. Identifying information
Addressee
Enter the proper applicant’s name and address information.
Office Address
Enter the FO or teleservice center address.
Date
Enter the date you issue the notice.
Social Security Number
Enter the claimant's SSN.
b. First paragraph
No fill-ins are required for the text.
c. Second paragraph
No fill-ins are required for the text.
d. Important reminder
This caption is mandatory.
e. Penalty of perjury
This caption is mandatory.
f. Penalty language
No fill-ins are required for the text.
g. If you have any questions
Fill-in 1: Enter the claims representative's (CR) name in the space provided.
Fill-in 2: Enter the CR's telephone number in the space provided.
Type the words “Application summary.”
2. Disposition of the notice
The witnessed signature cover notice will accompany the application that is returned to the proper applicant (either in person or by mail) for his or her records, as the person signed with a pen-and-ink signature, i.e., the application was not signed via attestation.
L. Exhibit — form attestation cover notice — (instructions on completing the notice follow the exhibit)
Social Security Administration
Supplemental Security Income
Important Information
Office Address:
Date:
Social Security Number:
On (1) , we talked with you and completed form(s) (2) . We stored the information on the form electronically in our records.
What You Need to Do
Review the enclosed form(s) to ensure we recorded your statements correctly.
If you agree with all your statements, you may retain the form(s) for your records.
If you disagree with any of your statements, you should contact us within 10 days after the date of this notice to let us know.
IMPORTANT REMINDER:
Penalty of Perjury
You declared under penalty of perjury that you examined all the information on this form and it is true and correct to the best of your knowledge. You were told that you could be liable under law for providing false information.
If You Have Any Questions
If you have any questions, you may call, write or visit any Social Security office. If you call or visit, please have this letter with you and ask for (3) . The telephone number is (4) . 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
Enclosure(s):
Form(s) (5)
Fill-in 1
Date of Interview (mm/dd/yyyy)
Fill-in 2
Enter the form number(s)
Fill-in 3
Claims representative’s (CR) name
Fill-in 4
The CR’s telephone number
Fill-in 5
Enter the form number(s)
1. Completing the DPS form attestation cover notice
After selecting the appropriate Title II or Title XVI header, and English or Spanish text, complete the DPS form attestation cover notice as follows:
a. Identifying information
Addressee
Enter the proper applicant’s name and address information.
Office Address
Enter the FO or teleservice center address.
Date
Enter the date you issue the notice.
Social Security Number
Enter the claimant’s SSN
b. First paragraph
Fill-in 1
Enter the date of the interview.
Fill-in 2
Enter the form number(s).
c. What you need to do
No fill-ins are required for the text under this caption.
d. Important reminder
This caption is mandatory.
e. Penalty of perjury
This caption is mandatory.
f. Perjury language
No fill-ins are required for the text.
g. If you have any questions
Fill-in (3) Enter the name of the claims representative (CR) in the space provided.
Fill-in (4) Enter the telephone number of the CR in the space provided.
h. Enclosure(s)
Fill-in (5) Enter the form number(s).
2. Disposition of the notice
For in-person interviews, the form attestation cover notice should accompany the form(s) given to the proper applicant for his or her records.
For telephone interviews, the form attestation cover notice should be mailed to the proper applicant with the form(s) for his or her retention.
M. Exhibit - printable interviewer's script
Use this English Version to view a printable English version of the interviewer's application script.
Use this Spanish Version to view a printable Spanish version of the interviewer's application script.