SSA-9000 - Old Version

Social Security Administration
Important Information
Local FO:
Return Address:

Date:
The Social Security Administration is committed to communicating
with you effectively. We have a process to help you, as a blind or
visually impaired person, to request an accommodation that will help
us communicate with you.
Requests We Automatically Approve
For blind or visually impaired persons, we automatically approve
requests for notices in standard print by first class or certified
mail, in Braille, or on Microsoft Word compact discs. We also
approve requests for standard print by first-class mail followed by
a telephone call from us. To request one of these formats, you
can:

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Form SSA-L9000 (05-2010)
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· Visit our website at www.socialsecurity.gov/notices and
follow the steps provided;
· Call us toll-free at 1-877-708-1776; or
· Write or visit your local Social Security office.
Other Requests for Accommodation
To request a different accommodation (such as large print or audio
compact disc), you can:
· Call us toll-free at 1-800-772-1213; or
· Call or visit your local Social Security office; or
· Fill out the enclosed “Request for Accommodation” form
and send it to: Social Security Administration, P.O. Box
17788, Baltimore, MD 21235-7788. You can also write to
this address about an accommodation request you have
already made.
When we decide whether or not to approve your request, we
will mail you our decision as well as the reasons we came to
that decision.

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Form SSA-L9000 (05-2010)
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If You Have Any Questions
For general information about Social Security, we invite you to
visit our website at www.socialsecurity.gov on the Internet. For
general questions and specific questions about your case, you
may call us toll-free at 1-800-772-1213, or call your local
Social Security office at
. We can answer most
questions over the phone. If you are deaf or hard of hearing,
you may call our TTY/TDD number at 1-800-325-0778. If you
do call or visit an office, please have this letter with you. It will
help us answer your questions.

Field Office Manager
Enclosure: SSA-9000-F4 Request for Accommodation

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Form SSA-L9000 (05-2010)
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Form Approved
OMB No 0960-0777

Social Security Administration

Request for Accommodation
REQUESTOR INFORMATION
1B. DATE OF REQUEST

1A. NAME
1C. ADDRESS

1D. SOCIAL SECURITY NUMBER
-

1E. PHONE NUMBER
(including area code)

-

ADDITIONAL INFORMATION
2. CONDITION THAT CAUSES YOU TO REQUEST AN
ACCOMMODATION

Form SSA-9000-F4 (05-2010)
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3. ACCOMMODATION REQUESTED

Please list the accommodation that would enable you to participate
fully.

4. EXPLANATION
Briefly describe why each of our currently offered accommodations
(standard print by first class or certified mail, Braille, Microsoft Word
file, and a telephone call), is not adequate for you:

Form SSA-9000-F4 (05-2010)
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Privacy Act otice for Request for Accommodation
The Rehabilitation Act of 1973 (as amended), 29 U.S.C. §§ 701 et seq., and
Section 205(a) of the Social Security Act (as amended), 42 U.S.C. § 405(a),
authorize us to collect this information. The information is needed to verify
your identity and to process your request for a notice accommodation.
Providing this information is voluntary. However, failure to provide all or
part of the requested information may prevent the Social Security
Administration from processing your request.
We rarely use the information you supply for any purpose other than for
verifying identity and processing your notice accommodation request.
However, we may use it for the administration and integrity of Social
Security programs. We may also disclose information to another person or to
another agency in accordance with approved routine uses, which include but
are not limited to: (1) to enable a third party or an agency to assist Social
Security in establishing rights to Social Security benefits and/or coverage; (2)
to comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and
Department of Veteran Affairs); (3) to make determinations for eligibility in
similar health and income maintenance programs at the Federal, State, and
local level; and (4) to facilitate statistical research, audit or investigative
activities necessary to assure the integrity of Social Security programs.

Form SSA-9000-F4 (05-2010)
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We may also use the information you provide in computer matching
programs. Matching programs compare our records with records kept
by other Federal, state or local government agencies. Information
from these matching programs can be used to establish or verify a
person's eligibility for Federally funded and administered benefit
programs and for repayment of payments or delinquent debts under
these programs.
Our notices, additional information regarding this application, and
information regarding our programs and systems, are available on-line
at www.socialsecurity.gov or at your local Social Security office.
Paperwork Reduction Act Statement - This information collection
meets the requirements of 44 U.S.C. § 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. We estimate that it will take about 20
minutes to read the instructions, gather the facts, and answer the
questions. You may send comments on our time estimate above to:
SSA, 6401 Security Blvd,Baltimore,MD 21235-6401. Send only
comments relating to our time estimate to this address, not the
completed form.

Form SSA-9000-F4 (05-2010)
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