Section 1611(c) of the Social Security Act, as amended, allows us to collect this information. We will use the information you provide to attempt to determine if you continue to be eligible for supplemental security income payments.

SSA-8202-BK, Statement for Determining Continuing Eligibility for Supplemental Security Income Payments

A WARRANT HAS BEEN ISSUED FOR YOUR ARREST - You must report to Social Security if: • You flee prosecution or to avoid custody or confine- • You violate a condition of your parole or probation under ment after conviction for a crime, or an attempt to Federal or State law.

authorize any employer, agency, or other organization to disclose to the Social Security Administration or the State agency that may determine or review my entitlement to disability benefits, any information about my physical and/or mental condition(s) or my work.

SSA-8202-F4-INST and SSA-8202-F4-SP-INST are the English and Spanish versions of the forms for use by all States except California. These versions include a food stamp message.

To comply with Federal laws requiring the release of information from Social Security records (e.g., to the Government Accountability Office and Department of Veterans' Affairs);

SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security office through SSA’s website at www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in

SSA uses Form SSA-8202-BK to conduct low and middle-error profile (LEP/MEP) telephone, or face-to-face redetermination interviews with SSI recipients and representative payees, if applicable. SSA conducts LEP redeterminations interviews on a 6-year cycle, and MEP redeterminations annually.

The form has 17 questions. The information is used to determine whether SSI recipients' have met and continue to meet all statutory and regulatory requirements for SSI eligibility and whether they have been and are still receiving the correct payment amount. Reason for Change SSA is seeking three changes to the SSA-8202-BK: 1. Question 7.

• You can apply for food stamps at the Social Security Office if you and everyone in your household get or apply for SSI. • The Social Security Office will help you fill out the food stamp application.