POD End of Year Reporting Form

Insert Date

Your POD Study ID:
StudyID#

Beneficiary First Name Beneficiary Last Name
Beneficiary Address 1, Beneficiary Address 2
Beneficiary City, State Zip

Dear Beneficiary First Name Beneficiary Last Name,
Each year, the Social Security Administration (SSA) compares the amount of SSDI benefits paid
to beneficiaries the previous year to the amount of benefits that should have been paid, based on
beneficiaries’ actual earnings for that year. This comparison is called the annual reconciliation
process. To conduct this reconciliation, SSA needs: 1) documentation of your monthly earnings;
and 2) documentation of your impairment-related work expenses (IRWEs) for any month in which
your IRWEs exceeded $840.
The table below lists the earnings and IRWEs that you previously reported to the POD project for
2017. The purpose of this letter is to ask if you have any additional earnings or IRWEs to
report for last year.

Month

Earnings

IRWEs

October 2017

$1,500

Below threshold

November 2017

$1,400

$900

December 2017

None submitted

None submitted

When reviewing the table to determine if you have any additional earnings or IRWE
documentation to submit for 2017, please note:
1) The first month for which you need to submit documentation is the month you enrolled in
POD: POD_RA_MONTHANDYEAR.
2) Earnings for a month are based on the date paid, not when earned.
3) If you do not report earnings for a month, SSA will use the earnings reported for the most
recently reported prior month to calculate your benefits.

4) You only need to submit documentation of IRWEs if they were greater than $840 for a
month.
5) Examples of IRWEs include co-payments for doctors’ visits, hospital in-patient or outpatient care or prescription drugs incurred due to a disabling condition, and special
transportation needs to and from work due to a disabling condition. Health care premiums
are not considered IRWEs.
The earnings and IRWE documentation you submit to the POD project will help SSA
determine the correct SSDI benefits due to you last year.
No Additional Documentation to Submit
If you do not have additional earnings or IRWE documentation to submit for 2017, complete the
following three steps:
1.

Check the box below.
I do not have additional earnings or IRWEs to report in the above-listed month(s).

2.

Sign and date here:

Signature
3.

Date

Return this form in the enclosed postage-paid envelope or via fax to .

Additional Documentation to Submit
If you have additional paystub or IRWE documentation for 2017, you can either report your
information electronically or by mail or fax. To report electronically, access this website and follow the instructions on the screen. Please report
electronically as soon as possible to ensure sufficient time to process your documentation before
SSA conducts the 2017 annual reconciliation, scheduled for late Summer 2018.
To report your information by mail or fax, complete the following four steps:
1.

Compile the additional documentation you want to submit to SSA.

2.

Sign and date here:

Signature
3.

Date

Return this signed form and the additional documentation in the enclosed postage-paid
envelope or via fax to as soon as possible to ensure sufficient time to

process your documentation before SSA conducts the 2017 annual reconciliation, scheduled
for late Summer 2018.
4.

Let the POD project know the best number and time to reach you in case we have questions
on what you submit.
Phone number:
Best time to reach me is:

Cell
AM

PM

Work

Home

(circle one)

(circle one)

Best day to reach me is:

Final Reminders
Please return any documentation you want to submit to POD as soon as possible. These items
will help determine if your benefits for 2017 were paid correctly. If you cannot locate
documentation you need to submit, or if you have questions about this request, please contact
, your POD work incentives counselor, at .
Sincerely,
POD Central Operations
Encl. (2)

Privacy Act Statement
Collection and Use of Personal Information
Section 234 of the Social Security Act, as amended, allows us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the
information may prevent you from participating in the Promoting Opportunities Demonstration
(POD) project.
We will use the information you provide to manage your participation in the POD project
and for research and statistics purposes. We may also share your information for the following
purposes, called routine uses:
1.

To contractors and other Federal agencies, as necessary, for the purpose of assisting the
Social Security Administration (SSA) in the efficient administration of its programs; and

2.

To a congressional office in response to an inquiry from that office made at the request of
the subject of a record.

In addition, we may share this information in accordance with the Privacy Act and other
Federal laws. For example, where authorized, we may use and disclose this information in
computer matching programs, in which our records are compared with other records for various
purposes related to the agency’s administration of Federal benefit programs, including ensuring
proper Federal benefit program payments.
A list of additional routine uses is available in our Privacy Act System of Records Notice
(SORN) 60-0218, entitled Disability Insurance and Supplemental Security Income
Demonstration Projects and Experiments System; 60-0090, entitled Master Beneficiary Record;
60-0103, entitled Supplemental Security Income Record and Special Veterans Benefits; 60-0094,
entitled Recovery of Overpayments, Accounting, and Reporting, and 60-0330, entitled eWork.
Additional information and routine uses, and a full listing of all our SORNs, are available on our
website at www.socialsecurity.gov/foia/bluebook.

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 the survey questions unless we display a valid Office of Management and Budget
(OMB) control number. The OMB control number for this collection is 0960-XXXX; expiration date XX/XX/20XX. We
estimate that it will take about 15 minutes to read the instructions, and answer the survey questions. You may send comments
about our time estimate to: Social Security Administration, 6401 Security Blvd, Baltimore, MD 21235-6401