1

Enter the name(s) and SSN(s) of the claimant(s) in the space provided on the form.

EXCEPTION: When a representative payee files the application, enter the representative payee's name followed by the word "for" and the name(s) of the claimant(s).

2

Enter the date the claim is filed.

3

Enter the telephone number and address of the servicing FO.

4

Enter (in the blank underlined area of the narrative) the estimated number of days it will take to hear from us. (An estimate of the number of days required for processing may be based on regional or local guidelines.)

5

Explain the Paperwork/Privacy Act Notice and computer matching statements as well as the burden estimate and request for comments (see GN 03360.015 and MSOM MSSICS 024.002).

6

Review the reporting responsibilities and answer any questions the applicant may have about the requirements. Remind the applicant about the penalty provision for failure to make a timely report.

7

Complete the "Changes to Report:"

• Prechecked items--Discuss the information with all claimants.

• Unmarked items--Discuss the information for each unmarked item as applicable to the claim and mark the appropriate block(s).

8

Tell the applicant that he/she should retain the "Changes to Report" page for later reference because:

• It provides written acknowledgement for filing an SSI claim and explains how to contact us; and

• The reverse side provides the changes to report.

Step

Action

1 - 7

Follow steps 1 - 7 in SI 00604.120B.2.

8

Detach tear-off page and retain it.

9

Upon receipt of the signed application form, follow procedures in GN 00201.015H.2. Provide the applicant with a cover note explaining the following:

1. The "Receipt for Claim" is enclosed; and

2. Purpose and importance of the "Changes to Report;" and

3. He or she must report changes because changes can affect payment. Call or write to the Social Security office identified on the "Receipt;".