Request For Additional Information

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We have received your claim for Blank line benefits. To complete the processing of your claim, we need additional information. Please mail the item(s) checked below within 10 calendar days in the enclosed, self-addressed envelope. Unless otherwise indicated, please do not send the originals.

Photocopy of identification showing your picture and your date of birth (For example, driver's license, Identification card, passport, permanent resident card, visa, Consular ID card).

Social Security Statement. You may contact the Social Security Administration (SSA) online at www.ssa.gov

Was this Social Security Number (SSN) assigned to you by the SSA? Yes or No (Circle your answer.)

Proof of wages paid to you by the employers for whom you worked from MM/DD/YYYY to MM/DD/YYYY (For example, photocopy of paycheck stubs and/or W2 forms. The SSA statement will not suffice.)

If you have worked under any other names, provide an explanation for working under that name and documentation (For example, photocopy of paycheck stubs and/or W2 forms. The SSA statement will not suffice.)

If you have worked under any other SSNs in the past, provide an explanation and documentation proving you worked under that SSN (For example, photocopy of paycheck stubs and/or W2 forms. The SSA statement will not suffice.)

Please respond within 10 calendar days from the date of this request. Failure to respond may result in denial of your claim.

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Department Representative

DE 2566 Rev. 6 (11-24) (INTRANET)

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DI / DE 2566

Request For Additional Information