TN 54 (11-06)

A. When To Use

The SSA-8202-F4-INST is enclosed with mail out SSA-8202-BK RZs.

B. Description

The SSA-8202-F4-INST is a 4-page form folded to 3-3/4" 8-1/2". There are four versions of the form:

• SSA-8202-F4-INST and SSA-8202-F4-SP-INST are the English and Spanish versions of the forms for use by all States except California. These versions include a food stamp message.

• SSA-8202-F4-INST-NFS and SSA-8202-F4- INST-SP-NFS are the English and Spanish versions of the forms for use by California only. These versions do not include a food stamp message.

All versions of the form include information about:

• Why we conduct RZs;

• How to complete the SSA-8202-BK;

• Timeframe for responding and the consequences of not responding;

• Recipient reporting responsibilities;

• Computer matching;

• Food stamps (in all States but California);

• Medicaid transfer of assets;

• Paperwork Reduction Act of 1995; and

• Privacy Act.

C. Procedure

Following is the procedure for use of the SSA-8202-F4-INST:

• Put the month/day/year you are mailing the form in the DATE block of two copies of the SSA-8202-F4-INST.

• Enclose a copy with the form SSA-8202-BK you are mailing to the recipient.

• Retain the other copy in the file to document the 30-day timeframe for close-out purposes.

D. References

• SI 02305.804 SSA-8202-F4-INST, Important Facts About Your Supplemental Security Income (FO, Food Stamp Version)