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REQUEST FOR RECORDS:, OSITIQN AUTHORITY(See Instructions on 1everse)-., LEAVE BLAN,{JOEl NOtJe,1-t11-1't-141-TO: GENERAL SERVICES ADMINISTRATION,NATIONAL ARCHIVES AND RECORDS SERVICE, WASHINGTON, DC20408DATE RECEJVED1. FROM (AGENCY OR ESTABLISHMENT)Department of Health, Education, and Welfare2 O JUN 1979NOTIFICATION TO AGENCY2. MAJOR SUBDIVISIONIn ar.cordance .,,!h the w·1v1s1ons of 44 U.SC 3303a the disposal request, rnclud,ng amendmp1ts, ,s approved except for ,terns that maybe stamped "d1spos;1 1ot approved" or "withdrawn" ,n column IO.Social Security Administration3. MINOR SUBDIVISIONI4. NAME OF PERSON WITH WHOM TO CONFER5. TEL EXT.594-5770Errest P. Lardieri6. CERTIFICATE OF AGENCY REPRESENTATIVE iul, 0r! -,,. ,u:;{4. .,-1 .Q,,y r.f r, hi,·i.,r of thi I mr,·d State.,I hereby certify that I am authorized to act for this agency in m ttys pertaining to the disposal of the agency's records;that the records proposed for disposal in this Request ofpage(s) are not now needed for the business ofthis agency or will not be needed after the retention periods specified.D A Request for immediate disposal.1 B Request for disposal after a specified period of time or request for permanentretention.C. DATE8.CRIPTION OF ITEM(With Inclusive Dates or Retention Periods)9.SAMPLE ORJOB NO.10.ACTION TAKENThe attached list of SSA program-related forms fallinto three categories of disposal instructions:Category 1: Documents or their equivalents are filedin claims folder and retained in accordance with claimsfolder disposition instructions. Documents in thiscategory have continuing value for program integrity,fraud, and audit purposes.Category 2: Documents or their equivalents are destroyedafter receipt of output or completion of action. Documents in this category are either input documents,documents requesting information that has been received,or are documents h requested an action and the actionhas been completed.Category 3: Documents or their equivalents are to bedestroyed immediately. Documents in this category haveno claims-related retention value.115-107STANDARD FORM 115Revised April, 1975Prescribed by General ServicesAdministrationFPMR (41 CFR) 101-11.4

t,INSTRUCTIONSGeneral Instructions:Use Standard- Form I I 5 (obtainable from supply depots of theFederal Supply Service. General Services Administration) and thecontinuation sheet Standard Form 115a (obtainable from the Records Disposition Division. Office of Federal Records Centers. National Archives and Records Service. Washington. D.C. 20408) to'.obtain authority to dispose of records or to request permanent retention of records. Detach the fifth copy from the set and keep asyour reference copy. Submit the first four copies of the set to theNational Archives and Records Service. One copy will be returnedto the agency as notification of items that are authorized for disposal.Items withdrawn or not approved for disposal will be so marked.Each SF 115 requiring Comptroller General concurrence must beaccompanied by a notification of approval from GAO.S pecijic Instructions:Entries I, 2, and 3 should show what agency has custody of therecords that are identified on the form. and should contain the nameof the depanment or independent agency. and its major and minorsubdivisions.Entries 4 and 5 should help identify and locate the person towhom inquiries regarding the records should be directed.Entry 6 should be signed and dated on the four copies by theagency representative. The number of pages involved in the requestshould be inserted.Box A should be checked if the records may be disposed of immediately. Box B sh uld be checked if continuing disposal authorityis requested or if permanent retention is requested. Only one boxmay be checked.Entry 7 should contain the numbers of the items of records identified on the form in sequence. i.e . I. 2. 3. 4. etc.Entry 1-i hould show what records are proposed for disposal.Cenl!r headings should indicate what office's records are involved if all records described on the form are not those of the sameoffice or if they are records created by another office or agency.An identification should be provided of the types of records involved if they are other than textural records. for example, if theyare photographic records. sound recordings. orcanographic records.-Ail itemization and accurate identification should be provided of(the series of records that are proposed for disposal or retention.Each series should comprise the la est practical ,grouping ofseparately organized a d logically related materials that can betreated as a single unit for purposes of disposal. Component pansof a series may be listed separately if numbered consecutively asI a. I b. etc., under the general series entry.A statement should be provided showing when disposal is to.· be made of the records. thus:If immediate disposal is requested of past accumulations of records, the inclusive dates during which the records were producedshould be stated.If continuing disposal is requested for records that have accumulated or will continue to accumulate, the retention period may beexpressed in terms of years. months, etc . or in terms of future actions or events. A future action or event that is to determine theretention period must be objective and definite. If disposal of therecords is contingent upon their being microfilmed. or otherwisereproduced or recorded on machine readable media, the retention period should read: "Until ascenained that reproduced copies orrecordings have been made in accordance with GSA regulationsand are adequate substitutes for the paper records." Also. the provisions of FJ:'MR § 101-11.5 should be observed.Entry 9 should be checked if samples are submitted for an item.However. samples of the records are not required unless they arerequested by the NARS appraiser. If an item has been previouslysubmitted. the relevant job and item number should be entered.Entr ,. JO should be left blank.'lf' ,·-.JJ 'rStandard Form 115 BACK (Rev. 4-75)

· Category 1 contains documents or their equivalents that are filed in the claims folder andretained in accordance with claims folder disposition instructions.Description of RecordsAuthorized DispositionI.RETIREMENT AND SURVIVORS rnsURANCECLAIMS FOLDERSA. Disatlowed life and death claims,withdrawals, and lump-sum only claims inwhich potential entitlement exists.Transfer to the Federal Records Center (FRC)after being so identified by the AutomatedFolder Inactivation stem (AFIS). Destroy,20 years thereafter(" :-y'k- / C ' R . J .B. Awarded claims where the last payment has been made and there is no futurepotential claimant indicated in the record,Transfer to the FRC after being so identified by the AFIS. Destroy 5- 7ear!;.,.L, thereafter, ( . , T - - , ·C. Awarded claims where payments haveended, but there is a future potentialclaimant indicated in the record.Transfer to the FRC after being so identified by the AF;J: S. Des tro7y , .,,. , \thereafter. { q,,' / rCt ? ::ir.,-3.II.DISABILITY INSURANCE CLAIMS CASEFOLDERSA,Disabilit;y Denial Claims\r ,;/ b? vTerminated Disabilit;y CasesIl.C.Transfer to the FRC after expiration of thereconsideration period and identificationas eligible for transfer by the case controlsystem. Destroy 20 ye thereafter.Transfer to the FRC after being identifiedas eligible for transfer by the ca e t r system. Destroy 20 years thereafter.(· Miscellaneous Freeze TerminationDestroy after 20 years'III, SUPPLEMENTAL SECURITY INCOME CLAD'iS·CASE FOLDERSTerminated or Disallowed ClaimsTransfer to the FRC after being so identified as terminated or disallowed by theAFIS or case control system. Destroy6 years and 6 months YJ reafter./'1/ /' / . , \/.The following documents or their equivalents are included in category 1: / INew NumberOld NumberSSA-1 F6SSA-1Application for Retirement Insurance BenefitsSSA-2 F6SSA-2Application for Wife's Insurance BenefitsSSA-3Husband's CertificationSSA-4 F6SSA-4Application for Child's Insurance BenefitsSS-5 FS FSS-5Application for an SS NumberTitleI1"'I'/ 61" retention in the.FRC.

Category 1New NumberOld NumberSSA-5 F6SSA-5Application for Mother's Insurance BenefitsSSA-6Application for Surviving Child's InsuranceBenefitsSSA-7Application for Parent's Insurance BenefitsSSA-8Application for Lump-Sum PaymentSSA-8ASupplement to Fol.'111 SSA-8SSA-1O F8ObsoleteSSA-1O andSSA-lOAApplication for Widow's Insurance BenefitsSSA-11 F6SSA-11Application to be Selected as PayeeObsoleteSSA-13Application for Widower's Insurance BenefitsObsoleteSSA-14Application for Husband's Insurance BenefitsSSA-15Wife's CertificationSSA-16Application for Disability Insurance BenefitsSSA-17Statement Regarding Disability (by Widow,Widower, Surviving Divorced Wife, or Child). SSA-18 F4SSA-18Application for Hospital Insurance BenefitsSSA-19 F6SSA-19Application for Special Age 72-or-OverMonthly PaymentsSSA-21 F4SSA-21Supplement to Claim of Person Outside theU.S.SSA-22 F4SSA-22Supplement to Claim on Behalf of a ChildOutside the U.S.ObsoleteOA-C24Application for Survivors BenefitsSSA-25Certificate or Election for Reduced Wife'sBenefitsSSA-4O4OSSA-4OAApplication for Medical InsuranceHCFA-4OBSSA-4O:BApplication for Enrollment under MedicareObsoleteSSA-43Application for Recalculation to IncludeAdditional Military Service Wage CreditsSSA-L5ONotice to Parent - Support Requirement MetSSA-L51Notice to Parent - Support Requirement NotMetSSA-8 F5,iI2

CatefjOry 1New NumberOld Number.!llliSSA-1O1OA-ClOlCOA-ClOlDDetermination of Award, Summary of ClaimDate-DIB ClaimSSA-L1O6Letter to School Requesting Verification ofAgeSSA-3924-U)SSA-107Determination of Resumption of AwardSSA-3927 ClSSA-3928 C2SSA-1O7eDetermination of Benefit Recomputationa:n.d/or RecalculationReport of Operation under Social Insuranceor Pension System(s)SSA-149Waiver of Benefit PaymentsSSA-2O1Determination of DisallowanceSSA-2O1BDetermination of Disallowance-DisabilityClaimObsoleteSSA-4O1Medical History and Disability ReportObsoleteSSA-4O1AReport of Disability Interview-Widow(Divorced Wife and Widower)ObsoleteSSA-4O1CHReport of Childhood Disability Interview,SSA-416BDI Medical Consultant's Case AnalysisSSA-4JOAMedical Development SummaryOA-D439Authorization to Release Notice of Determination and Request for Medical InformationSSA-L439Ineligibility Letter for Disabled WidowsBenefitsSSA-45OSSSI Data Input and DeterminationSSA-454Report of Continuing Disability InterviewSSA-454ASocial Security Disability BeneficiaryReportHA-5O1-USHA-5O1Request for HearingHA-5121-U)SSA-512.1Notice by Attorney of Appointment asRepresentativeHA-52O-U6HA-52ORequest for Review of Administrative LawJudge's ActionsSSA-521Request for Withdr wal of ApplicationSSA-439 U)iI3

eCategory 1New NumberOld NumberSSA-5525-UJSSA-5526-O4SSA-525 andSSA-525BRequest for Evidence or AssistanceHA-L-53O-U.5HA-53OAuthorization to Charge and Receive a FeeSSA-533Translation RequestSSA-553Special DeterminationSSA-561-U2SSA-561Request for ReconsiderationSSA-562-UJSSA-562Request for Assistance/Certification ofDocument(s) or Record(s)SSA-562ARequest for Assistance/Certification bySchool OfficialsRepresentative Payee 23B(PR)Representative Payee 4PRSSA-632-F4SSA-632Re.t'und QuestionnaireSSA-633-UJSSA-633Agreement to Re.t'und OverpaymentObsoleteSSA-634"Without Fault" QuestionnaireSSA-635Finding that Recovery and/or Adjustment ofOverpayment is BarredSSA-639Report of Uncollectible IndebtednessSSA-651Certification of Award of Benefits underSection 217(b) of the S.S. Act, as 8lllendedSSA-654Request for Information from UniformedServicesSSA-655Certification by Federal Agency as to Payments on Account of VeteranSSA-662Reconsideration DeterminationSSA-669FRequest for Benefits Payable-BeneficiaryOutside U.S.SSA-62)-C2SSA-655-U2TitleiI4

Category 1New NumberOld Number SSA-7O2Statement Regarding Date of BirthSSA-7O4Certification of Contents of Document(s)or Record(s)SSA-7O4DDO-TEL Telephone Confirmation of EvidenceReceived in the DOSSA-7O6Request for Information from World War IDraft RecordsSSA-L7O6Letter to Custodian of Birth RecordsSSA-I,7O7·. Letter to Custodian of Marriage RecordsSSA-L716"L.etter Requesting Information from the· :District Director of Internal Revenue SSA-717Statement of Person Requesting Paymenton Behalf of EstateSSA-718Consent by Relative for Payment to Individual on Behalf of EstateObsoleteSSA-719Statement of Burial Expenses by FuneralDirectorSSA-723-F4SSA-723Statement Regarding the Presumed Death ofan Individual by Reason of his Continuedand Unexplained AbsenceSSA-L725Letter to Employer Requesting EarningsInformationSSA-L726BSecond Followup and Close-out LetterSSA-L732Request to Claimant to Obtain AdditionalInformationSSA-L733Ineligibility Letter-Life-DeathSSA-L733AIneligibility Letter, Survivol.'-DecedentNot InsuredSSA-753Statement Regarding MarriageSSA-754Statement of Marital Relationship (By One ofthe Parties)SSA-76OCertificate of Support (Parent's, Husband's,or Widower's)SSA-L-1O45 U2SSA-76O-F45

Category 1New NumberOld NumberTitleSSA-763Supplemental Statement Regarding IncomeSSA-764Supplemental Statement Regarding Incomefrom Farming and/or Gardening ActivitiesSSA-766Statement of Self-Employment IncomeSSA-767Certification of Evidence of Self-EmploymentIncomeSSA-768Certification of Evidence of WagesSSA-780-F4SSA-780Certificate of Applicant for Benefits onBehalf of AnotherSSA-788SSA-780AStatement of Person with Whom :Beneficiary isLivingObsoleteCertificate of Responsibility for WelfareSSA-781and Care of Child not in Applicant's CustodyObsoleteSSA-782Statement of Person with Whom the Child isLivingSSA-783Statement Regarding ContributionsSSA-784Retirement or Disability Insurance BenefitQuestionnaireAuthorized Disposition1. Claim filed: File in claims folder.Retain in accordance with claims folderdisposition instructions.2.SSA-785No claim filed:Destroy after 6 months.Questionnaire Regarding Survivors Insurance:BenefitsAuthorized Disposition1. Claim filed: File in claims folder.Retain in accordance with claims folderdisposition instructions,2./6No claim filed:Destroy after 6 months,

Category lNew Number SSA-786Physician's Statement (Patient's Capabilityto Manage Benefits)SSA-787Medical Officer's Statement (Patient'sCapability to Manage Benefits)SSA-794Earnings Record-PIA DeterminationSSA-795SSA-795PRStatement of Claimant or Other PersonSSA-807Request for Field ContactSSA-L8O8.lDisability Denial LetterSSA-L8O8.2Not Disability - Impairment is Severe ButNot Expected to Last 12 Months - Not InsuredSSA-821Work Activity Report-EmployeeSSA-821AReport of Work Activity-Continuing DisabilitySSA-821BWork Activity Report-Self-Employed PersonSSA-824Report on Individual with Mental ImpairmentSSA-825-SPSSA-825SSA-825PRAuthorization to SSA to release MaterialInformationSSA-3826-F4SSA-826Medical Report-GeneralSSA-3827SSA-826CHMedical Report-Individual with ChildhoodImpairmentSSA-3828SSA-826.1Medical Report-Pulmonary TuberculosisSSA-828-U4OA-D828Request for Medical Information from Recordsof Veterans AdministrationSSA-829-U4SSA-829Request for Medical Information fromMilitary Facilities or Records CentersSSA-831-USSSA-831Disability Determination and TransmittalSSA-833-U5SSA-833Cessation or Continuance of DisabilityDetermination and TransmittalSSA-8J4-U5SSA-834Continuance Sheet for Disability DeterminationSSA-L855Ineligibility Letter-DisabilitySSA-795 SPfOld NumberI7

Category 1/New NumberOld NumberSSA-881 U)SSA-881Request for Field Investigation of Continuing DisabilitySSA-883Request for Evidence or Assistance(Disability Case)SSA-1OOO TRSSA-1OOOClaims Data DisplaySSA-1OO1SSA-lOOlFRStatement of EmployerSSA-lOOlSPSSA-10O2SSA-1OO2PRStatement of Agricultural EmployerSSA-1OO2SPSSA-1O4OC0-1O4OReduced DIB after RIB WorksheetSSA-1129 U)SSA-1129Attorney Fee Case-Past Due BenefitSSA-1178Evaluation of Fee Petition for RepresentationSSA-1255Statement of Institution or Social AgencySSA-1268 ClSSA-1268Record of Returned CheckObsoleteSSA-13O3Certification of Disability DeterminationSSA-1323Request for Information from School orAgency (Report on Individual with ChildhoodImpairment)SSA-1344Chinese Custom Marriage Statement (by One ofthe Parties)SSA-1345Statement Regarding Chinese Custom MarriageSSA-1372Student's Statement Regarding SchoolAttendanceSSA-1372ACertification by School OfficialSSA-1372A.lRequest for District Office Assistance toObtain Completed Form SSA-1372ASSA-1372A(F)Statement to U.S. SSA by School Outside theU.S. About Student's AttendanceSSA-1372BStudent's Statement Regarding SchoolAttendanceSSA-1)72FStudent's Statement Regarding SchoolAttendance Outside the U.S.Title8Summary

Category 1New NumberOld NumberSSA-1388-TCSSA-1388SSA-1388FSSA Report of Student Beneficiary at Endof School YearSSA-1389 ClSSA-1389Report of Student Beneficiary About toAttain Age 22SSA-1426Statement About Disability by PersonOutside of U.S.SSA-1458Certification by Religious GroupSSA-1560Petition to Obtain Approval of a Fee forRepresenting a S.S. ClaimantSSA-1560AAuthorization to Charge and Receive a FeeSSA-1578Underpayment under Title II of the S.S.Act to Legal Representative of Estate ofDeceased BeneficiarySSA-1585Notice of Medical Insurance Enrollment andPremium Deduction (Printed prior to 9/69)SSA-1596 ClSSA-1596Record of Changes in Premium Deduction orBilling StatueSSA-1600-UJSSA-1600Request for Claim Number VerificationSSA-1610-UJSSA-1610Social Security-Public Assistance AgencySSA-1560-U4Obsolete.1!.lliInformation Request and ReportObsoleteSSA-1659Affidavit Showing Right to Receive Moneyunder Section 630 of the CaliforniaProbate CodeSSA-1696-UJSSA-1696Appointment of RepresentativeSSA-1697-U3SSA-1697Notice to Representative of ClaimantBefore the Social Security AdministrationSSA-1709-U4SSA-1709Request for Workmen's CompensationInformationSSA-1724Claim for Amounts Due in the Case of aDeceased BeneficiarySSA-1760SSA-1760SPVoluntary Statement to Explain IrregularitySSA-1760 SRHCFA-1763SSA-1763Request for Termination of SMISSA-1774BDI Transmittal to State AgencyII9

e.Category 1New NumberOld NumberObsoleteSSA-18)2TitleVeteran Leads Program--SS BenefitsAuthorized Disposition1. Claim filed: File in claims folder.Retain in accordance with claims folderdisposition instructions.2.No claim filed:Destroy after 6 months.Request for Program Service Center ThirdSSA-1899Party ActionHealth Insurance CardSSA-1966Authorized Disposition1. If undeliverable, immediate destructionauthorized.2 . If returned by claimant refusingMedicare Part B insurance, file in claimsfolder. Retain in accordance with claimsfolder disposition instructions.SSA-2038Date of Birth DeterminationSSA-2052DO Review of DDS Determinations, Statementof DeficienciesSSA-2080DO Final Authorization ClaimSSA-2190Change in Method of Computing Net Earningsfrom Self-EmploymentSSA-23))SSA-2)3)AApplication for Benefits by a MentalInstitution on Behalf of a PatientSSA-2417Redetermination of Benefit RightsSSA-.2455Workmen's Compensation Offset ED Medical Consultant Staff-PsychiatricReviewSSA-2512Military Service QuestionnaireSSA-2514Record of Claimant's Intent to FileSSA-2519Child Relationship StatementIRS-2190/10Medical Consultant Staff-Review

Category lNew NumberSSA-2795 U)Old Number1!lli.SSA-2647Request for Information from World War IISelective Service RecordsSSA-2788Health Evaluation ReviewSSA-2795Determination of Resumption of AwardSSA-2872 .Statement of Death and Burial Expenses byFuneral DirectorAuthorized Disposition1. · If filed with claim: File in claimsfolder. Retain in accordance with claimsfolder disposition instructions.2. If not filed with claim:3 months.SSA-2876Confirmation of School AttendanceSSA-5OO2Report of ContactSSA-7OO0-U6SSA-7OOONotice of Determination of Self-EmploymentIncomeSSA-7OO1-PCSSA-7OO1Postal Card Requesting Address fromPostmasterOAAN-7OO3Request for Change in Your SS RecordsSSA-7O1ONotice of Determination of FICA WagesSSA-7O11Statement of EmployerObsoleteSSA-7O12Request for Information Contained inDirector's FilesSSA-7O13OAR-7O1)Statement Regarding Wages by Person HavingKnowledge ThereofSSA-7O1O-U7SSA-7O57Request to IRS for Inspection or Copy of TaxReturnU)SSA-7155-F4iDestroy afterSSA-71O4Partnership QuestionnaireSSA-7155Domestic Service QuestionnaireSSA-7156Farm Self-:Employment QuestionnaireSSA-7156AFa.rm Arrangement Questionnairei11

Category 1New U2Old NumberTitleSSA-7160Employment Relationship QuestionnaireSSA-7163Questionnaire About Employment or SelfEmployment Outside the U.S.SSA-7163.ASupplemental Statement Regarding FarmingActivities of Person Living Outside the U.S.SSA-7201Employer's Constructive Payment QuestionnaireSSA-7202Employee's Constructive Payment QuestionnaireSSA-7203Sick Pay and Plan or System QuestionnaireSSA-7204General Wage QuestionnaireSSA-7207Employee's Subject-to-Call QuestionnaireSSA-7208Employer's Subject-to-Call QuestionnaireSSA-7210Traveling Expense QuestionnaireSSA-8000Application for SSI (Couple)SSA-8001Application for SSI (Individual)SSA-8002Application for SSI (Individual with Spouse)SSA-8010Statement of Income and ResourcesSSA-8015SSA-8016SSI Deeming Worksheet (Spouse to Spouse)SSI Deeming Worksheet (Parent to Child)SSA-8025ASSI Payment DecisionSSA-80JOASSI Notice of Disapproved ClaimSSA-8040SSI Application to be Selected PayeeSSA-8050SSI Referral NoticeSSA-8060Agreement to Sell PropertySSA-8108SSI Overpayment and Disposition DeterminationSSA-8109SSI Payment Computation SummarySSA-8110SSI Manual One-Time PaymentSSA-8114Request for Payment of SSI Benefits DueSSA-8081SSI Redetermination Review Form12

Category 1New NumberOld NumberSSA-L8151-U2SSA-8151ASSI Notice of ChangeSSA-L8155-U2SSA-8155ASSI Notice of Planned ActionSSA-L8165-U2SSA-8165ASSI Notice of DecisionSSA-L8170-U2SSA-8170ANotice of Overpayment-Adjustment ProposedSSA-L8171-U2SSA-8171ANotice of Overpayment-Refund RequestedSSA-8173ANotice of Disapproved Waive AdjustmentProposedSSA-8174ANotice of Disapproved Waive Re.fundRequestedSSA-8190Representative Payee Report for SSISSA-8200Statement of Determining ContinuingEligibility for SSI PaymentsSSA-8450District Office Record of SSI Reconsideration DecisionSSA-8455ASSI Notice of ReconsiderationSSA-8740Referral and Treatment Status of SSI Drug.Addicts or AlcoholicsSSA-9.585Representative Payee Onsite Review Program(:Beneficiary Information Report)SSA-8190 C2SSA-L8455-U2!!lliOTHER AGENCIES'FORMSjIRS-4137Computation of Social Security Tax onUnreported Tip IncomeVA Form10-2339Statement of Hospitalization or OutpatientTreatmentVA Form10-2545Report of Medical Examination for DisabilityEvaluationVA Form21-4182Application for Dependency and IndemnityCompensation or Death Pension (IncludesAccrued Benefits and Death CompensationWhere Applicable) from the VeteransAdministrationI13

Category 1New NumberOld NumberTitleOTHER DOCUMENTS1. Certified copies of proofs, such asproof of birth, marriage and death, whichare maintained by other government entities(State, local, Federal).2.Medical evidence.3. Appellate Decisions (claims folder copyof the reconsideration, hearing, and AppealsCouncil review).j14

Category 2 contains documents or their equivalents that are destroyed after receipt ofoutput or completion of action, Exceptions are noted.Authorized DispositionNew NumberOld NumberSSA-4500-U6OAR-S)OFederal Detennination ofError in State's WageReportsDestroy after outputreceived/action completed.SSA-250Development Worksheet1. Destroy 6 months aftercompletion of development.2.If received in review-ing office, destroy uponcompletion of action,Destroy after outputreceived/action completed.Destroy after outputreceived/action completed.SSA-38450 299Trial Work Period Tally SheetObsoleteSSA-449BDI Request for DO and DDSAction on ReconsiderationCaseSSA-450Claims Input Data·Destroy 1 calendar monthafter receipt of aclmowledgment from BDP.SSA-450AALSO Input DataDestroy 1 calendar monthafter receipt of aclmowledgment from BDP.SSA-450:BSubsequent Claims InputShort Fonn 450Destroy 1 calendar monthAfter receipt of aclmowledgment from BDP,SSA-450CClaims Input DataDestroy 1 calendar monthafter receipt of acknowledgment from BDP.SSA-504 a.ndSSA-504:BDO Record of Claims Development Continuation SheetIf received in reviewingoffice, destroy uponcompletion of action.Transmittal by BRADestroy upon completionof action.ObsoleteHA-5051-UJHA-505,1Transmittal of HearingDecision or DismissalDestroy upon completionof action,ObsoleteSSA-5)9Authorization for Change inName or Designation of PayeeDestroy after outputreceived/action completed.SSA-5)90-U2SSA-539AAuthorization for Change inPayee Designation or CodingDestroy after outputreceived/action completed.i/15

Category 2New NumberOld NumberSSA-555-U)SSA-555Request for Action-DelayedPaymentDestroy after outputreceived/action completed.SSA-559Transmittal Slip for ClaimsFoldersDestroy after outputreceived/action completed.SSA-567Notice for Subsequent HandlingSSA-569 andSSA-569AClaims Folder RequisitionRSI Program Center ClaimsFolder RequisitionDestroy after outputreceived/action completed,Destroy after outputreceived/action completed.SSA-573Special Instruction NoticeDestroy after outputreceived/action completed,SSA-580Interoffice CommunicationObsoleteC0-0586Transmittal Memo forModificationsDestroy after outputreceived/action completed.Destroy after outputreceived/action completed,SSA-591SSA-591 andSSA-59lllAIncoming Correspondence Assignment RecordDestroy after outputreceived/action completed.SSA-600EDPFolder RequisitionDestroy upon receipt offolder.SSA-612NAReport of New Information inDisability CasesDestroy after outputreceived/action completed.SSA-569-U2SSA- 3598-U)andTitleAuthorized DispositionObsoleteSSA-612PR (NA)SSA-6)6-UJSSA-J58J-U2SSA-636 andSSA-6)6BDITransmittal Notice-Hearing Case Destroy after outputTransmittal Notice-Hearing Case- received/action completed.DisabilitySSA-641C0-0641Flag NoticeObsoleteSSA-650VA PaymentsDestroy after outputreceived/action completed,Destroy after outputreceived/action completed,SSA-666Adjustment in Trust FundAccountsDestroy after outputreceived/action completed.SSA-667SSA-667BIdentification of ClaimsMaterialDestroy after outputreceived/action completed.ObsoleteOA-C668(F)Claimant's Report to VeteransAdministrationDestroy after outputreceived/action completed.ObsoleteOA-C670Request for Address ofMilitary PersonnelDestroy after outputreceived/action completed,Request for Certification of16

New NumberOld NumberCat0.gory 2TitleAuthorized DispositionSSA-671Railroad EmploymentQuestionnaireDestroy after outputreceived/action completed.ObsoleteSSA-168OExtension of Filing TimeMemorandumDestroy after outputreceived/action completed.ObsoleteSSA-721Statement of Death byFuneral DirectorDestroy 3 months afterreceipt of source document, except as stated onpage 28.*ObsoleteSSA-725Request for Suspension orTermination of BenefitsDestroy 3 months afterlast action.*Exception: Foreignannulment decrees willcontinue to be retainedin accordance with existingpolicies and procedures.SSA-735-TCSSA-735Notice of Missing SocialSecurity CheckDestroy 45 days afterreceipt.SSA-746Notice to Adjust EarningsRecordsDestroy upon completion ofaction.SSA-1747Letter Requesting EvidenceDestroy after outputof Current Year Self-Employment received/action completed.IncomeSSA-748Request for District OfficeInvestigation of AnnualDestroy upon completion ofaction.EarningsSSA-777Annual Report of Earninge1974Destroy 3 months afterlast action.SSA-777PRDestroy 3 months afterlast action.SSA-777SSA-777BDestroy 3 months afterlast action.ObsoleteSSA-777-1Destroy 3 months afterlast action.ObsoleteSSA-777.lPRDestroy 3 months afterlast action.ObsoleteSSA-777.2ADestroy 3 months afterlast action.*Posteligibility notices, which supplant the redetermination form and are themselves thebasis for the redetermination decision, are to be retained in the same fashion as theredetermination form itself.17

Catee;:o!l 2New NumberOld NumbP.rObsoleteSSA-777,3Destroy 3 months afterlast action.ObsoleteSSA-777,4Destroy 3 months afterlast action.ObsoleteSSA-777,4ADestroy 3 months afterlast action.·obsoleteSSA-777,5Destroy 3 months afterlast action.ObsoleteSSA-777,9Destroy 3 months afterlast action.ObsoleteSSA-777,9PRDestroy 3 months afterlast action.ObsoleteSSA-777,9ADestroy 3 months afterlast action.ObsoleteSSA-777,10Destroy 3 months afterlast action. SSA-79ORR·oA-C79O(IDP).'ll.lliRequest for Earnings RecordActionSSA-822Notice of Subsequent ClaimDisability DeterminationPendingDestroy after outputreceived/action completed,ObsoleteSSA-822ANotice of Subsequent ClaimRRS Disability DeterminationPendingDestroy after outputreceived/action completed.ObsoleteSSA-823Request for Medical Evidenceto Hospital or InstitutionDestroy after disabilitydetermination is made.SSA-827FSSA-827Authorization to ReleaseMedical Information to theSocial Security AdministrationDestroy after disabilitydetermination is made.i/Destroy upon adjudicationof claim or completion ofaction.SSA-822-U2I/Authorized DisEosit!on18

Category 2New NumberOld NumberObsoleteSSA-827AClaimant's Authorization toAttending PhysicianDestroy after disabilitydetermination is made.SSA-827BGeneral Authorization forMedical InformationDestroy after disability4etermination is made.SSA-L-8J5ASSA-L8J5Request to Beneficiary forContinuing Disability ReviewDestroy after outputreceived/action completed.ObsoleteOA-D840(IDP)Request for Earnings RecordDisabilityDestroy after adjudicationof claim or completion ofaction.ObsoleteSSA-848Transmittal to SSA-EDInestroy after outputreceived/action completed.SSA-852C0-852Correspondence Search RecordDestroy after output ·received/action completed.SSA-856C0-856DIE Case Folder FlagDestroy after outputreceived/action completed.SSA-862Request for Earnings (EarningsRecord Information)Destr

SSA-561-U2 SSA-562-UJ . SSA-62)-C2 . Obsolete Obsolete . SSA-625 Obsolete SSA-632-F4 SSA-633-UJ Obsolete . SSA-655-U2 Old Number . SSA-525 and SSA-525B HA-53O SSA-533 SSA-553 SSA-561 SSA-562 . SSA-562A . SSA-623 SSA-62JA SSA-623B SSA-623B(PR) SSA-624 SSA-624A SSA-624B SSA-624PR . SSA-632 . SSA-633 . SSA-63

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