Form SSA-9310 Request for Documents

FORM APPROVED

OMB No. 0960-0707

SOCIAL SECURITY ADMINISTRATION

Office of Quality Assurance and

Performance Assessment

(Address of Office)

Date:

Beneficiary Name:

SSN:

(Address)

On (fill-in), I spoke with you regarding the review of (fill-in). In order to proceed with the review, the following is needed:

(fill-in)

Please send the requested documents in the enclosed self-addressed, postage-paid envelope. We will return your documents immediately.

If you have questions about this request, contact me at 1-800-(fill-in) between 8:00 a.m. and 4:00 p.m., Monday through Friday.

Thank you for your cooperation.

Sincerely,

Social Insurance Specialist

Enclosure(s)

PAPER REDUCTION ACT NOTICE

Paperwork Reduction Act Statement – This information collection meets the requirements of 44 U.S.C section 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. The OMB number for this collection is 0960-0707. We estimate that it will take about 15 minutes to read the instructions, gather the facts, and answer the questions. Send only comments on our time estimate above to: SSA, 1338 Annex Building, Baltimore, MD 21235-0001.

Request for Documents

SSA-9310 (04/2007)