Statement for Determining Continuing Eligibility for Supplemental Security Income Payment--Adult/Statement for Determining Continuing Eligibility for Supplemental Security Income.....

SOCIAL SECURITY ADMINISTRATION
Instructions for Completing Form SSA-3988-0CR-SM

WbyWe're
Sending You
The Enclosed
Form

We must regularly review the cases of people who get Supplemental Security Income
(SSI). We check to be sure that each person is still eligible and we are sending the right
amount of money.
As part of your review, we need you to answer the questions on the enclosed form.
It's called Statement For Determining Continuing Eligibility for Supplemental
Security Income Payments, SSA-3988-0CR-SM. If you have a representative payee
(that's someone who receives your SSI payment for you), he or she must complete the
form.
In the enclosed booklet "IMPORTANT FACTS ABOUT SSI" we'll go over some
other important facts. We'll explain:
• Changes you need to report to us.
• Computer matching, Medicaid, and transfer of resources

Instructions for Completing the SSA-3988-0CR-SM
How to Complete
Form
SSA-3988-0CR-SM

Here are some things to remember when you are completing the SSA-3988-0CR-SM.
• Use a black ink pen or a #2 pencil.
• - Piease-ahswer all the questlons Wifl10ne exception. DO NOT ANSW~~ Question
15 if you live in:
Nevada
Indiana
Alaska
Oklahoma
Kansas
Connecticut
New Hampshire
Oregon
Minnesota
North Dakota
Hawaii
Utah
Missouri
Northem Mariana Islands
Idaho
Virginia
Nebraska
Ohio
Illinois
• If you are completing the form for a child, answer questions as ifthe child were
completing the form.
• If you are completing the form because you are a representative payee; sign your
name in the representative payee space.
• Answer "Yes" or "No" questions by marking an "X" inside the "Yes" or "No" boxes.
• Print dates like this: Month/Day/Year, For example, you would print July 4, 2006
like this: 07/04/2006.
• Show dollar amounts only, do not show $ and do not show dollars and cents. For
example, show $600.55 as 600.
• If you answer a question "Yes," also complete all the additional questions. For
example, if you answered Question 7-Have you or your spouse spent a full
calender month in a hospital, nursing home, or other institution? -"Yes," you
would write in the dates you or your spouse entered and left.

Form SSA-3988-0CR-SM-NFST-INST (7-2006)

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CDOP

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A calendar month is all of the days in a month. For example, if you were admitted
to a hospital on November 23 rd and were discharged on January 4th, the full
calendar month is December.

•

For Questions 9 and 10, earned income is money you, your spouse or if you are a
child, your parent(s) receive from work or from owning your own business.

•

For Question 11, unearned income is money you, your spouse or, if you are a child,
your parent(s) receive from a source other than work or self employment, such as
interest on bank accounts, pensions or welfare.

•

For Question 13, resources are things that you, your spouse or, if you are a child,
your parent(s) own and can use to get food or shelter. Resources can be:

•
•

Cash;
Real property (a house or land); or
Personal property such as a car, bank accounts, or investments like stocks,
bonds or life insurance.

•

Sign your name in the space marked Your Signature. Your spouse signs in the
space marked Husband's or Wife's Signature ONLY if both of you get SSI
checks.

•

Check the address that we have for you. If it's wrong, give us the correct address in
Question 3.

• If you need more space to answer a question, continue your answer in the
REMARKS section on page 11. For example, in Question 4 if 6 people live with
you, enter the name, relationship, date of birth and Social Security Number for 5
persons in Question 4 and the name, relationship, date of birth and Social Security
Number for the 6th person in REMARKS on page 11.
If you have any questions or need help completing the form,
call us at 1-800-772-1213.

When to Return The
SSA-3988-0CR-SM

Please return your completed form to us in the enclosed envelope within 30 days
from the date you receive the form.

If We Don't Hear

Your SSI payments will stop if:

From You

•

You do not return the completed SSA-3988-0CR-SM to us;
OR

• You do not contact us to let us know you are having problems completing the
form.
Before we stop payments, we will send you a letter. The letter explains our action
and what to do if you think we are wrong.
Form SSA-3988-0CR-SM-NFST-INST (7-2006)

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