MONTHLY REPORT OF EARNINGS
MONTHLY REPORT OF EARNINGS
Social Security Administration Date____________________
__________________________
__________________________
__________________________
Attn: Supplemental Security Income (SSI) Claims Representative
My name is ____________________________________________________________
Social Security # ________________________________________________________
I am working at ____________________________________________________
Address ____________________________________________________
Phone # ____________________________________________________
Supervisor ____________________________________________________
Enclosed are my pay stubs for the month of ___________________________________
I would like to use the ___________________________Work Incentive.
I have enclosed the necessary information.
Please apply this information to my file.
Thank you,
Signature Date
Address ____________________________________________________________
____________________________________________________________
Phone Number ______________________________________________________
................
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