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Protective Filing Letter — Intent to Apply for Social Security Disability Benefits
[YOUR FULL NAME]
[STREET ADDRESS]
[CITY, STATE ZIP]
Phone: [PHONE NUMBER] · Email: [EMAIL]
Social Security Administration
[LOCAL SOCIAL SECURITY OFFICE NAME]
[OFFICE STREET ADDRESS]
[CITY, STATE ZIP]
[DATE]
Sent by: [CERTIFIED MAIL NUMBER / HAND DELIVERED AND STAMPED ON DATE]
Re: Written statement of intent to claim benefits (protective filing) — [YOUR FULL NAME], SSN [YOUR SOCIAL SECURITY NUMBER]
Dear Sir or Madam,
I intend to apply for Social Security disability insurance benefits on my own earnings record. [I ALSO INTEND TO APPLY FOR SUPPLEMENTAL SECURITY INCOME (SSI).] I am writing now so that the date of this statement can be used as my application filing date, as provided in 20 CFR 404.630 [AND 20 CFR 416.340].
1. My details
Full name [YOUR FULL NAME]
Other names used [MAIDEN OR OTHER NAMES, OR "NONE"]
Social Security number [YOUR SOCIAL SECURITY NUMBER]
Date of birth [MM/DD/YYYY]
Mailing address [ADDRESS ABOVE OR OTHER]
Phone [PHONE NUMBER]
2. What I am claiming
I have been unable to work since about [DATE YOU STOPPED WORKING OR BECAME DISABLED] because of [SHORT DESCRIPTION OF CONDITION]. I intend to file my application this month, [ONLINE / BY TELEPHONE / AT AN APPOINTMENT AT YOUR OFFICE].
[OPTIONAL: I also intend to claim benefits for my [SPOUSE / CHILDREN] [NAMES] if my claim is approved.]
3. What I ask you to do
Record [DATE YOU RECEIVE THIS LETTER, OR THE POSTMARK DATE IF THAT PROTECTS MORE BENEFITS] as my protective filing date for disability insurance benefits [AND SSI].
Send me the notice that tells me the date by which I must file the application, or contact me to schedule an appointment at [PHONE NUMBER].
If you need anything else from me to protect this date, tell me in writing.
I understand that this statement does not replace the application itself and that I must file the application within the time stated in your notice.
Sincerely,
____________________
[YOUR SIGNATURE — HANDWRITTEN, NOT TYPED]
[YOUR FULL NAME]
[IF SIGNED BY SOMEONE ELSE: Signed on behalf of [CLAIMANT'S NAME] by [YOUR NAME], [RELATIONSHIP, E.G. SPOUSE / PARENT / LEGAL GUARDIAN], [PHONE NUMBER].]
For me
[ ] Letter signed by hand, copy kept
[ ] Mailed by certified mail on [DATE], or delivered and stamped on [DATE]
[ ] SSA notice dated [DATE] — SSDI application due within 6 months, SSI within 60 days: [LAST DAY]
[ ] Application filed on [DATE], confirmation number [NUMBER]