I-4-3-112.Sample — Letter Advising Claimant of Proffer Through the Field Office

Last Update: 9/13/05 (Transmittal I-4-15)


Social Security Administration




Refer to:



Office of Hearing and Appeals
5107 Leesburg Pike
Falls Church, VA 22041-3200


Claimant's Name
City, State ZIP

Dear __________________:

I have received additional evidence which I propose to include in the record of your case. (See enclosed LIST OF ADDITIONAL EVIDENCE.) I am sending this evidence to the Social Security office shown below. They will notify you when the evidence is available for your examination, and give you 10-days to come to the office to examine it. Because your case is now within my jurisdiction, personnel in the Social Security office will not be permitted to discuss the evidence with you or to provide you with copies of it.

You should make any comments you wish to make about the evidence in writing on the form provided at the Social Security office. If you have additional evidence or any statement to make as to the facts and law in your case, you may also submit them. If you want me to forward the evidence to your treating physician, please so indicate and provide the physician's name and address.

You may request a supplemental hearing with respect to this evidence and if required for a full and true disclosure of the facts in your case, you may request to orally question the author(s) of this (these) report(s).

The Social Security office will tell me if they do not hear from you within 10 days of the date of their notice. I will then assume that you do not wish to examine or comment on the evidence or request a supplemental hearing, and that you have no further documentation to submit. I will carefully consider your case and issue a decision on the evidence of record.

Sincerely yours,

Administrative Appeals Judge


      (list the additional evidence)

cc: Social Security Office
(Street Address)
(City, State)