Form SSA-L8050-U3 Supplemental Securrity Income Claim Information Notice

FORM APPROVED
OMB NO. 0960-0324

SOCIAL SECURITY ADMINISTRATION
Supplemental Security Income
Claim Information

Office Address:

•

Telephone Number:
Contact Person:
Date:
Social Security Number:

We are writing to let you know that you may be able to receive a benefit from the organization
shown at the bottom of this page. We need to know if you can receive benefits from this
organization so that we can make a decision about your Supplemental Security Income
(SSI) payments.
You must apply for and take any action needed to receive benefits from this organization by

.

If you do not take action by this date:
• You will not be eligible for SSI.
• You will have to pay back any SSI you may have received beginning

.

• We will send you another letter that explains our decision and what you can do if you
think we are wrong before we take any further action on your claim.
If you want to receive SSI payments, you must apply for any benefits you can get now. In some
cases, you can get a lower benefit if you apply now but a higher benefit if you apply later. You have
to take whatever benefit the organization will give you now to receive SSI.
Please take or mail the enclosed form to the organization shown below right away. When the
organization returns the form to us, we will make a decision about your SSI payments.
You also have the option of applying for Social Security benefits online at www.
socialsecurity.gov. If you have any questions, please get in touch with the Social Security office
shown above.
Manager
Organization Name and Address
•

Form SSA-L8050-U3 (12-2013) EF (12-2013)

FORM APPROVED
OMB NO. 0960-0324

SOCIAL SECURITY ADMINISTRATION
Supplemental Security Income
Claim Information

Office Address:

•

Telephone Number:
Contact Person:
Date:
Social Security Number:

Organization Name and Address
•

FIELD OFFICE COPY

Form SSA-L8050-U3 (12-2013) EF (12-2013)

FORM APPROVED
OMB NO. 0960-0324

SOCIAL SECURITY ADMINISTRATION
Supplemental Security Income
Claim Information

Office Address:

Refer To:
•

Telephone Number:
Contact Person:
Date:
Social Security Number:

The person whose name and address is shown above may be eligible for benefits from you.
We have asked this person to apply for benefits from your organization.
We told this person to apply for benefits from your organization no later
than

.

We need the information about benefits from your organization to decide if this person is eligible to
receive Supplemental Security Income (SSI). In some cases, the person can get a lower benefit if
they apply now but a higher benefit if they apply later. In order to get SSI, the person whose name
is shown above will have to take whatever benefit your organization will give now.
Please fill out Part 3 on the back of this page and return it to us in the enclosed postage paid
envelope.
Thank you for your assistance.
Enclosure

Manager
Organization Name and Address
•

Form SSA-L8050-U3 (12-2013) EF (12-2013)

PART 1 TO BE COMPLETED
BY THE
INDIVIDUAL

Please let me know how to file a claim for a pension, annuity, or benefit from your organization.
I hereby authorize the Social Security Administration to release the information shown below. I also
authorize your organization to release any information to the Social Security Administration about any
claim I have filed or intend to file with your organization.
SIGNATURE

DATE

This information refers to
PART 2 TO BE COMPLETED NAME
BY THE SOCIAL
SECURITY
SSN
ADMINISTRATION

Other

Claimant

RELATIONSHIP
DATE OF BIRTH

DATES OF MILITARY SERVICE

SERIAL OR OTHER IDENTIFYING
NUMBER
FROM

TO

FROM

TO

BRANCH OF SERVICE

DATES OF EMPLOYMENT
PLACE OF EMPLOYMENT

PART 3 TO BE COMPLETED
BY THE
ORGANIZATION

Ineligible

Refused to Apply

Expect Decision

Claim Approved

by

Will Contact Individual

(Date)

SIGNATURE

DATE

TITLE

PHONE NO. (Include Area Code)

See Revised Privacy Act
Statement Attached

Privacy Act and Paperwork Reduction Act Statements

Sections 1611(e)(2) and 1612(a)(2)(B) of the Social Security Act,
as amended, authorize us to collect this information. This
information is needed to determine if you qualify for benefits from
the listed organization and a possible adjustment to your
Supplemental Security Income (SSI). The information you
provide on this form is voluntary, however, failure to provide the
requested information may adversely impact your SSI benefits.
We rarely use the information you supply for any purpose other
than for establishing benefit eligibility. 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 the following: (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; (4) To State agencies providing
services to disabled children; and (5) To facilitate statistical
research, audit or investigative activities necessary to assure the
integrity of Social Security programs.

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.
A complete list of routine uses for this information is available in
System of Records Notices 60-0103. The notice, additional
information regarding this form, and information regarding our
programs and systems, are available on-line at www.ssa.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 (OMB) control number. The OMB control
number for this collection is 0960-0324. We estimate that it will take
10 minutes to read the instructions, gather the facts, and answer the
questions. Send only comments relating to our time estimate above
to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

Form SSA-L8050-U3 (12-2013) EF (12-2013)