Form SSA-263 (09-2023)
Discontinue Prior Editions Page 1 of 2
Social Security Administration OMB No. 0960-0783
WAIVER OF SUPPLEMENTAL SECURITY
INCOME PAYMENT CONTINUATION
NAME OF CLAIMANT SOCIAL SECURITY NUMBER
This refers to the advance notice of planned action I received on , 20 .
• I have been advised of the proposed action (reduction, suspension, or termination) concerning my
Supplemental Security Income (SSI) payments. I fully understand the results will have on my monthly
payment amounts.
• I understand that I have the right to continuation of unreduced payments until a decision is made on
my initial appeal request.
• I understand I may request my unreduced payments be reinstated at any time up to the date I receive
a decision on my initial appeal. I understand this includes any retroactive payments back to the month
they were reduced, suspended or terminated.
• I understand my rights. I request the Social Security Administration (SSA) take immediate action to
make the change in my payments.
• My rights have been explained to me. I voluntarily sign this form.
Your Signature (If you sign with an X, two people must witness below) Date (MM/DD/YYYY)
Mailing Address (Number and Street, City, State, Zip Code) Telephone Number
(include area code)
Your statement does not have to be witnessed. If, however, you have signed by marking an (X), two
witnesses must sign below and provide their complete address.
1. Signature of Witness 2. Signature of Witness
Address of Witness #1 Address of Witness #2
(Number and Street, City, State, Zip Code) (Number and Street, City, State, Zip Code)
Form SSA-263 (09-2023) Page 2 of 2
PRIVACY ACT STATEMENT
Collection and Use of Personal Information
Sections 205(a), 1631(a)(7), and 1631(e)(1)(A) of the Social Security Act, as amended, and
CFR 20 § 416.1336(d) allow us to collect this information. Furnishing us this information is voluntary.
However, failing to provide all or part of the information may prevent us from making a timely and accurate
decision on any claim filed.
We will use the information to further document your claim and make a decision regarding your Social
Security benefits. We may also share your information for the following purposes, called routine uses:
• To State agencies to enable them to assist in the effective and efficient administration of the
Supplemental Security Income program; and
• To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social
Security Administration (SSA) in the efficient administration of its programs. We will disclose
information under this routine use only in situations in which SSA may enter a contractual or similar
agreement with a third party to assist in accomplishing an Agency function relating to this system of
records.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For
example, where authorized, we may use and disclose this information in computer matching programs, in
which our records are compared with other records to establish or verify a person's eligibility for Federal
benefit programs and for repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 60-0103,
entitled Supplemental Security Income Record and Special Veterans Benefits, as published in the Federal
Register on January 11, 2006, at 71 FR 1830. Additional information, and a full listing of all of our SORNs,
is available on our website at www.ssa.gov/privacy.
Paperwork Reduction Act Statement
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the
Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid
Office of Management and Budget control number. We estimate that it will take about 5 minutes to read the
instructions, gather the facts, and answer the questions. 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 your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
You may send comments regarding this burden estimate or any other aspect of this collection, including
suggestions for reducing this burden to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only
comments relating to our time estimate or other aspects of this collection to this address, not the
completed form.
