TN 26 (03-92)

Social Security Administration

Supplemental Security Income

Notice of Appointment

                   Office Address:

                   Social Security Number:

                   Date:

This is a very important letter about keeping your Supplemental Security Income (SSI) case active. Please read it carefully. If there is anything you do not understand, please get in touch with us right away.

You Have An Appointment

We must regularly review the cases of people who get SSI. We need information from you to make sure you are still eligible.

We have set up an appointment for you on      at      . On that date:

• Call us at      and ask for      .

• We will call you at     . Let us know if this number is wrong.

• Come to see us at        and ask for     .

• Your representative payee must come with you to the appointment.

If you can't keep your appointment, please call us. We will make another appointment for you.

If We Do Not Hear From You

We may stop your SSI if you don't respond to this request or contact us by      to tell us why. If we stop your SSI, you could also lose any Medicaid you have now.

Before we stop your SSI, we will send you another letter to explain our decision. The letter will also explain your right to appeal the decision and how to continue getting SSI during the appeal.

                  See Next Page

                                Form SSA-L3074-U3

                              Page 2 of 2

Things We Need for the Appointment

When you talk with us, please try to have all of the items checked for      to the present. 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.

• Bank statements: savings and checking accounts, and any other bank statements for       

• Pension records from: the Department of Veterans Affairs, Railroad Retirement Board, Civil Service, State, military, private pensions for     

• Pay stubs from work since     for      

• For self-employment, last year's income tax return; if not available, all records that show last year's business income and expenses for        

• Unemployment compensation payment records for       

• Worker's compensation award letter for      

• Life insurance policies for      

• Burial contract agreement for       

• Other

   

   

We must see the original document(s) or a certified copy of these item(s). We cannot accept photocopies. We will return these items to you.

When you call or come in, please have this letter with you.

If You Have Any Questions

If you have any questions or need help, please call us at     and ask for     .

                     Office Manager

Enclosure(s):

                                Form SSA-L3074-U2