TN 19 (08-12)

A. When to use SSA-L8009-U3

Use the SSA-L8009-U3 in initial claims situations to request information or evidence. For reference purposes, SI 02306.020 contains the notices used in post eligibility situations. For additional failure to cooperate information, see DI 11018.000.

B. Description of the SSA-L8009-U3

The SSA-L8009-U3 and the SSA-L8009-U3 SP consist of three copies, an;

1. original,

2. follow-up, and

3. file.

The forms are available via the Document Processing System (DPS), which replaced the Distributed Online Correspondence System (DOCS).

C. Policy for SSA-L8009

1. Who should receive the notice

See NL 00801.001B for the policy on who should receive the SSA-L8009-U3.

2. Uses of the notice

Use the SSA-L8009-U3 in initial claims situations to:

• request information or evidence;

• ask the claimant to come in or call in to obtain additional information or evidence;

• ask the claimant to call the field office (FO) to discuss a specific topic when it is not necessary to schedule an appointment;

• advise the claimant of a scheduled appointment; and

• request the claimant to sign and return a form(s) other than a Supplemental Security Income (SSI) application.

NOTE: Instruct alien claimants to bring evidence of immigration status to the FO. Remind alien claimants not to send immigration document(s) through the mail since aliens are required to have their immigration document(s) in their possession at all times. (For documentary evidence on qualified alien status, see SI 00502.130.)

D. Failure to submit evidence procedure chart

The following chart highlights the current process.

Title XVI Initial Claims Disposition Process – Failure to Submit Evidence

E. Procedure for completion of the notice

1. DPS fill-ins

To complete the notice fill-ins, follow instructions on the DPS screens. Retain a dated copy of the notice to document the 30-day closeout period using the Online Notice Retrieval System (ONRS). It is important to include a copy of the dated notice in the Electronic File (EF). For document retention requirements, see SI 00601.120F.

2. Preprinted notice fill-ins

Complete the SSA-L8009-U3 as follows.

a. Separate the pages

Tear off the perforated tab at the top of the notice to separate pages 1 and 2 before completing.

b. Identifying information

Enter the following identifying information:

• the FO address,

• the hours the FO is open to the public,

• the FO’s telephone number, or the claims representative's (CR's) direct telephone number,

• the date you give or mail the notice to the addressee,

• the claimant's SSN.

c. “What You Need To Do” section

Place an "X" in the appropriate block(s).

• Block 3

  Enter the telephone number the person you are requesting information from should call and the name of the contact person in the appropriate spaces.

• Block 4

  Enter the date (month/day/year) and the telephone number we will call.

• Block 5

  Enter the date (month/day/year) and the name of the contact person.

If you check block 3, 4, or 5, complete the last sentence. The fill-in is the reason or topic that we need to discuss.

d. “If We Do Not Hear From You” section

Enter the closeout date (month/day/year), which is 30 calendar days from the date of the initial contact.

e. “Things We Need” section

Check the block(s) that applies to the evidence you are requesting.

• First paragraph-- Enter the date (month/day/year) for which the evidence is needed.

• Blocks 1-2-- Enter either:

  1. the name of the person for whom the evidence is needed (e.g., claimant, worker, bank account holder), or

  2. “you” (if the person you are requesting information from is the addressee).

• Block 3

  First entry

  Enter the date (month/day/year) of the first pay stub you are requesting.

  Second entry

  1. Enter the name of the person for whom you need to verify earnings, or

  2. “you” (if the person you are requesting information from is the addressee).

• Blocks 4-8

  Enter:

  1. the name of the person for whom the evidence is needed (e.g., claimant, worker, bank account holder), or

  2. ” You” (if the person you are requesting information from is the addressee).

• Block 9

  Enter any other information or evidence not specifically listed on the notice.

f. “If You Have Any Questions” section

Enter the name of the contact person in the space provided.

g. “Enclosure(s)” section

List all enclosures.

F. Procedure for documenting the claims file

Document the claims file as follows.

1. Retain the file copy of the SSA-L8009-U3 in the claims folder until the claimant complies with the request.

2. If we deny or suspend the claim, retain a copy of the SSA-L8009-U3 in the claims folder to support the determination.

   NOTE: Document the claims file with the type of evidence or information requested and the date of the request. Do not maintain a copy of the development request if we store the document electronically. When you receive the evidence or information, destroy any paper copy of the request (see GN 00301.150). If the claimant completes a paper form, fax the form into the Non-Disability Repository for Evidentiary Documents (NDRed).

G. Exhibit

SSA-L8009-U3

To view the form, go to SSA-L8009–U3.

Social Security Administration
Supplemental Security Income
Important Information (IC)

Office Address:

  

Office Hours:

  

Phone:

  

Social Security Number:

  

Date:

This letter is very important and could affect whether you can get Supplemental Security Income (SSI). Please read it carefully. If there is anything you do not understand, please get in touch with us right away.

What You Need To Do

We need more information to decide if we can pay you SSI. Therefore, it is important that you do the following: (Only the checked boxes apply to you.)

[_] Mail or bring in the item(s) checked on page 2 along with this letter as soon as­ possible.

[_] Sign and date the enclosed form(s). Return the form(s) and this letter in the enclosed envelope as soon as possible.

[_] Call __________________ and ask for _________________________________.

[_] We will call you on ____________________at ______________________. Please let us know if this telephone number is wrong or if this is not a good time for you.

[_] Come to see us on _____________________ and ask for __________________. The office address is at the top of this letter.

If we have asked to talk to you, it is because we need to discuss _________________ ________________________________________________________________________.

If We Do Not Hear From You

We may deny your application for SSI if you don’t respond to this request or contact us by _____________________ to tell us why. If we deny your application, we will send you another letter to explain our decision. The letter will also explain your right to appeal.

                                                        (See Next Page)

                                                                                       Form SSA-L8009-U3 (7/95)

                                                                                                Use 8/92 Edition Until Exhausted

                                                                                                    Page 2 of 2

Information about Medicaid

In many States, applying for SSI means you also are applying for Medicaid. If we deny your SSI application, you cannot get Medicaid based on SSI.

Things We Need

We need to see the items checked below for ______________________________

to the present. Even if you don’t have all of the information, we need to hear from you. We will help you get anything you do not have.

[_] Bank statements: savings and checking accounts, and any other bank statements for _________________________________________________

[_] Pension records from: the Department of Veterans Affairs, Railroad Retirement Board, Civil Service, State," military, private pensions for _______________________________________________________________

[_] Pay stubs from work since ____________________ for ___________________

[_] For self-employment, last year's income tax return; if not available, all records that show last year's business income and expenses for _____________________________

[_] Unemployment compensation payment records for ____________________

[_] Worker's compensation award letter for ______________________________

[_] Life insurance policies for ___________________________________________

[_] Burial contract agreement for _______________________________________

[_] Other _____________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

We must see the original document(s) or a certified copy of the item(s). We cannot accept photocopies, except for income tax returns. We will return the item(s) to you. If you call or come in, please have this letter with you.

If You Have any Questions

If you have any questions or need help, please call us at the telephone number at the top of this letter and ask for ____________________________________.

                                                                                              Manager

Enclosure(s):                                                                                                       Form SSA-LS009-U3 (7/95)

H. References

• SI 00601.110 Closeout - Failure to Cooperate (N18) - Initial Claims

• SI 02301.235 Failure to Provide Information (N20)

• DI 11018.000 Failure to Cooperate and Whereabouts Unknown