TN 24 (12-94)
NL 00804.260 Automated Overpayment Notice (AONS)
These paragraphs appear on the manual overpayment forms (i.e., SSA-L8170-U3, SSA-L8171-U3,
SSA-L8172-U3). The paragraphs are listed in the order they should appear on the notice.
In this chapter, “Situation Where Used:” only appears where an explanation is required.
2900. We are writing to let you know that we've paid (1) (2) too much Supplemental Security Income (SSI) money. The overpayment happened (3) . (4) overpaid (5) (6) (7) (8)
-
(1)
Choice 1 - you
Choice 2 - (Name of recipient)
-
-
(3)
Choice 1 - in (Month/Year)
Choice 2 - in (Month/Year) and (Month/Year)
Choice 3 - from (Month/Year) through (Month/Year)
-
(4)
Choice 1 - You were
Choice 2 - She was
Choice 3 - He was
-
(5)
Choice 1 - because
Choice 2 - for the following reasons.
Choice 3 - for several reasons.
-
(6)
Choice 1 - The first reason was because
Choice 2 - The second reason was because
Choice 3 - The third reason was because
Choice 4 - Null
-
(7)
Choice 1 - of your
Choice 2 - of her
Choice 3 - of his
Choice 4 - of your spouse's
Choice 5 - of her spouse's
Choice 6 - of his spouse's
Choice 7 - of your parent's
Choice 8 - of her parent's
Choice 9 - of his parent's
Choice 10 - of your parents'
Choice 11 - of her parents'
Choice 12 - of his parents'
Choice 13 - of (Name of essential person)'s
Choice 14 - of (Name of essential person)'
Choice 15 - of the
Choice 16 - of an increase in your
Choice 17 - of an increase in her
Choice 18 - of an increase in his
Choice 19 - of an increase in your spouse's
Choice 20 - of an increase in her spouse's
Choice 21 - of an increase in his spouse's
Choice 22 - of an increase in your parent's
Choice 23 - of an increase in her parent's
Choice 24 - of an increase in his parent's
Choice 25 - of an increase in your parents'
Choice 26 - of an increase in her parents'
Choice 27 - of an increase in his parents'
Choice 28 - of an increase in (Name of essential person)'s
Choice 29 - of an increase in (Name of essential person)'
Choice 30 - of an increase in the
Choice 31 - you were
Choice 32 - she was
Choice 33 - he was
Choice 34 - you
Choice 35 - she
Choice 36 - he
Choice 37 - your
Choice 38 - her
Choice 39 - his
Choice 40 - your spouse was
Choice 41 - her spouse was
Choice 42 - his spouse was
Choice 43 - Null
-
(8)
Choice 1 - Social Security benefits.
Choice 2 - Black Lung benefits.
Choice 3 - Veterans benefits.
Choice 4 - Railroad benefits.
Choice 5 - assistance payments based on need.
Choice 6 - help you got to pay the cost of your food, clothing or shelter.
Choice 7 - help she got to pay the cost of her food, clothing or shelter.
Choice 8 - help he got to pay the cost of his food, clothing or shelter.
Choice 9 - pension.
Choice 10 - pensions.
Choice 11 - support from your parent.
Choice 12 - support from her parent.
Choice 13 - support from his parent.
Choice 14 - worker's compensation.
Choice 15 - income from interest, dividends, rents or royalties.
Choice 16 - gifts, prizes, cash or special income.
Choice 17 - share of your sponsor's income.
Choice 18 - share of her sponsor's income.
Choice 19 - share of his sponsor's income.
Choice 20 - share of your sponsor's and your sponsor's spouse's income.
Choice 21 - share of her sponsor's and her sponsor's spouse's income.
Choice 22 - share of his sponsor's and his sponsor's spouse's income.
Choice 23 - wages.
Choice 24 - income from being self-employed.
Choice 25 - living in a public institution.
Choice 26 - outside the United States.
Choice 27 - resources were more than a person could own and still get SSI.
Choice 28 - did not file for other benefits.
Choice 29 - refused training that may help you go to work.
Choice 30 - refused training that may help her go to work.
Choice 31 - refused training that may help him go to work.
Choice 32 - refused treatment for drug addiction.
Choice 33 - refused treatment for alcoholism.
Choice 34 - refused treatment for drug addiction and alcoholism.
Choice 35 - not a citizen of the United States or legally allowed to stay in the United
States.
Choice 36 - dis not return an SSI check after you told us to stop sending them.
Choice 37 - did not return an SSI check after she told us to stop sending them.
Choice 38 - did not return an SSI check after he told us to stop sending them.
Choice 39 - living in a medical care facility.
Choice 40 - getting food and shelter in someone else's home or apartment.
Choice 41 - paid after your eligibility for payments based on blindness ended.
Choice 42 - paid after her eligibility for payments based on blindness ended.
Choice 43 - paid after his eligibility for payments based on blindness ended.
Choice 44 - paid after your eligibility for payments based on disability ended.
Choice 45 - paid after her eligibility for payments based on disability ended.
Choice 46 - paid after his eligibility for payments based on disability ended.
Choice 47 - not blind.
Choice 48 - not disabled.
Choice 49 - help your spouse got to pay the cost of food, clothing and shelter.
Choice 50 - help her spouse got to pay the cost of food, clothing and shelter.
Choice 51 - help his spouse got to pay the cost of food, shelter.
Choice 52 - Null
2901. (1) Later in this letter, we'll give you a detailed explanation of (2) (3) overpayment.
-
(1)
Choice 1 - This new overpayment is in addition to the old overpayment we are now collecting.
You still owe ($$$.¢¢) from the old overpayment.
Choice 2 - This new overpayment is in addition to the old overpayment we are now collecting.
She still owes ($$$.¢¢) from the old overpayment.
Choice 3 - This new overpayment is in addition to the old overpayment we are now collecting.
He still owes ($$$.¢¢) from the old overpayment.
Choice 4 - This overpayment is in addition to the advance payment we are now collecting.
You still owe ($$$.¢¢) from the advance payment.
Choice 5 - This overpayment is in addition to the advance payment we are now collecting.
She still owes ($$$.¢¢) from the advance payment.
Choice 6 - This overpayment is in addition to the advance payment we are now collecting.
He still owes ($$$.¢¢) from the advance payment.
Choice 7 - This new overpayment is in addition to the old overpayment and the advance
payment we are now collecting. You still owe ($$$.¢¢)
Choice 8 - This new overpayment is in addition to the old overpayment and the advance
payment we are now collecting. She still owes ($$$.¢¢) from the old overpayment and
the advance payment.
Choice 9 - This new overpayment is in addition to the old overpayment and the advance
payment we are now collecting. He still owes ($$$.¢¢) from the old overpayment and
the advance payment.
Choice 10 - This new overpayment is in addition to the old overpayment already on
your record. You still owe ($$$.¢¢) from the old overpayment.
Choice 11 - This new overpayment is in addition to the old overpayment already on
her record. She still owes ($$$.¢¢) from the old overpayment.
Choice 12 - This new overpayment is in addition to the old overpayment already on
his record. He still owes ($$$.¢¢) from the old overpayment.
Choice 13 - This overpayment is in addition to the advance payment made to you. You
still owe ($$$.¢¢) from the advance payment.
Choice 14 - This overpayment is in addition to the advance payment made to her. She
still owes ($$$.¢¢) from the advance payment.
Choice 15 - This overpayment is in addition to the advance payment made to him. He
still owes ($$$.¢¢) from the advance payment.
Choice 16 - This new overpayment is in addition to the old overpayment and the advance
payment already on your record. You still owe ($$$.¢¢
Choice 17 - This new overpayment is in addition to the old overpayment and the advance
payment already on her record. She still owes ($$$.¢¢) from the old overpayment and
the advance payment.
Choice 18 - This new overpayment is in addition to the old overpayment and the advance
payment already on his record. He still owes ($$$.¢¢) from the old overpayment and
the advance payment.
Choice 19 - Null
-
(2)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(3)
Choice 1 - new
Choice 2 - Null
2941. NOTE: This paragraph replaces 2902.
(1) must pay us back unless we decide (2) shouldn't have to pay us back or we're wrong about the overpayment. If you think
(3) shouldn't have to pay us back or think we're wrong, you can:
Fill-ins:
-
(1)
Choice 1 - You
Choice 2 - She
Choice 3 - He
-
(2)
Choice 1 - you
Choice 2 - she
Choice 3 - he
-
(3)
Choice 1 - you
Choice 2 - she
Choice 3 - he
2903. Situation Where Used:
Used only on the SSA-L8170. Informs the overpaid individual that we intend to collect
overpayment via monthly check adjustment.
If We Don't Hear From You In The Next 30 Days
We plan to collect this (1) overpayment from (2) SSI checks. (3) .
If you ask for waiver or appeal in the next 30 days, we won't (4) until we decide (5) case.
-
(1)
Choice 1 - new
Choice 2 - Null
-
(2)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(3)
Choice 1 - We'll hold back ($$$.¢¢) each month starting with (Month/Year) until you
have paid us back.
Choice 2 - We'll hold back ($$$.¢¢) each month starting with (Month /Year) until she
has paid us back.
Choice 3 - We'll hold back ($$$.¢¢) each month starting with (Month /Year) until he
has paid us back.
Choice 4 - We'll hold back ($$$.¢¢) in (Month/Year) to collect the overpayment.
Choice 5 - We'll hold back ($$$.¢¢) in (Month/Year) and ($$$. ¢¢) in (Month/Year)
to collect the overpayment.
Choice 6 - We'll hold back your check each month starting with (Month/ Year) until
you have paid us back.
Choice 7 - We'll hold back her check each month starting with (Month/Year) until she
has paid us back.
Choice 8 - We'll hold back his check each month starting with (Month/Year) until he
has paid us back.
Choice 9 - We'll hold back your check for (Month/Year) to collect the overpayment.
Choice 10 - We'll hold back her check for (Month/Year) to collect the overpayment.
Choice 11 - We'll hold back his check for (Month/Year) to collect the overpayment.
Choice 12 - We'll hold back your checks for (Month/Year) and (Month/
Choice 13 - We'll hold back her checks for (Month/Year) and (Month/Year) to collect
the overpayment.
Choice 14 - We'll hold back his checks for (Month/Year) and (Month/Year) to collect
the overpayment.
Choice 15 - We'll hold back your check for (Month/Year) and ($$$.¢ ¢) in (Month/Year)
to collect the overpayment.
Choice 16 - We'll hold back her check for (Month/Year) and ($$$.¢ ¢) in (Month/Year)
to collect the overpayment.
Choice 17 - We'll hold back his check for (Month/Year) and ($$$.¢ ¢) in (Month/Year)
to collect the overpayment.
Choice 18 - We'll continue holding back your check each month until you have paid
back the old and the new overpayments.
Choice 19 - We'll continue holding back her check each month until she has paid back
the old and the new overpayments.
Choice 20 - We'll continue holding back his check each month until he has paid back
the old and the new overpayments.
Choice 21 - We'll continue holding back ($$$.¢¢) each month until you have paid back
the old and the new overpayments.
Choice 22 - We'll continue holding back ($$$.¢¢) each month until she has paid back
the old and the new overpayments.
Choice 23 - We'll continue holding back ($$$.¢¢) each month until he has paid back
the old and the new overpayments.
Choice 24 - We'll change the amount we hold back each month from ($$$. ¢ ¢) to ($$$.¢¢).
This will start in (Month/Year). It will continue until you have paid back the old
and the new overpayments.
Choice 25 - We'll change the amount we hold back each month¢¢) to ($$$.¢¢). This will
start in (Month/Year). It will continue until she has paid back the old and the new
overpayments.
Choice 26 - We'll change the amount we hold back each month from ($$$. ¢ ¢) to ($$$.¢¢).
This will start in (Month/Year). It will continue until he has paid back the old and
the new overpayments.
Choice 27 - We will collect the advance payment first. Then, we will begin collecting
the overpayment from your check.
Choice 28 - We will collect the advance payment first. Then, we will begin collecting
the overpayment from her check.
Choice 29 - We will collect the advance payment first. Then, we will begin collecting
the overpayment from his check.
-
(4)
Choice 1 - start collecting the new overpayment
Choice 2 - change your check
Choice 3 - change her check
Choice 4 - change his check
-
(5)
Choice 1 - your
Choice 2 - her
Choice 3 - his
2942. NOTE: This paragraph replaces 2904.
If You Think (1) Shouldn't Have To Pay Us Back
(2) may not have to pay us back. Sometimes we can waive an us back. We can do this if
both of the following are true.
-
•
It wasn't (4) fault that (5) got too much SSI money.
AND
-
•
Paying us back would mean (6) can't pay (7) bills for food, clothing, housing or medical care, or it would be unfair for some
other reason.
If you think these are true about (8) , contact any Social Security office. You can ask for a waiver any time by asking
your Social Security office to fill out the waiver form. The waiver form number is
SSA-632. We won't collect the overpayment while we decide if we can waive it.
-
(1)
Choice 1 - You
Choice 2 - (Name of recipient)
-
(2)
Choice 1 - You
Choice 2 - She
Choice 3 - He
-
(3)
Choice 1 - you
Choice 2 - she
Choice 3 - he
-
(4)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(5)
Choice 1 - you
Choice 2 - she
Choice 3 - he
-
(6)
Choice 1 - you
Choice 2 - she
Choice 3 - he
-
(7)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(8)
Choice 1 - you
Choice 2 - her
Choice 3 - him
2905. Situation Where Used:
There is representative payee data on the new record. (This language is found on the
SSA-L8176-U2 which is a manual notice that goes to the representative payee.)
Special Message for Representative Payees
If the overpayment is not repaid by (1) or from (2) funds, we will ask you to repay it from your own money. If (3) begins to repay us, but stops before the overpayment is will ask you for any amount
remaining. But we won't ask you to repay us if both of the following are true.
-
•
You used the SSI check(s) for (4) needs.
AND
-
•
It was not your fault that (5) was overpaid.
Please let us know as soon as possible if you think both of these facts are true.
In addition, we won't ask you to repay us from your own money for any month(s) of
overpayment in which you were not the representative payee. If you were not the payee
for any of the overpayment months, please tell us. If there was a payee before you,
and you have that person's name and address, please give it to us. You can contact
any Social Security office.
-
-
(2)
Choice 1 - her
Choice 2 - his
-
(3)
Choice 1 - she
Choice 2 - he
-
(4)
Choice 1 - her
Choice 2 - his
-
(5)
Choice 1 - she
Choice 2 - he
2906. Situation Where Used:
Appeal rights. Appears only on the SSA-L8170 version of the overpayment forms.
Do You Think We're Wrong?
If you think we're wrong, you have the right to appeal. We'll correct mistakes. We'll
look at any new facts you have.
-
•
You have 60 days to ask for an appeal. If you ask in the next 30 days, we won't change (1) case.
-
•
Both the 30 day and the 60 day periods start the day after you get this letter.
-
•
You'll have to have a good reason for waiting more than 60 days to ask for an appeal.
-
•
To appeal, you must fill out a form called “Request for Reconsideration.” The form number is SSA-561. To get this form, contact one of our offices. We can
help you fill out the form.
How To Appeal
There are three ways to appeal. You can pick the one you want. If you meet with us in person, it may help us decide
(2) case.
-
•
Case Review . You have a right to review the facts in (3) file. You can give us more facts to add to (4) won't meet with the person who decides (6) case.
-
•
Informal Conference . You'll meet with the person who decides (7) case. You can tell that person why you think you're right. You can give us more facts
to help prove you're right. You can bring other people to help explain (8) case.
-
•
Formal Conference . This is a meeting like an informal conference. The difference is we can make people
come to help prove you're right. We can make them bring important papers about (9) case, even if they don't want to help you. You can question these people at your
meeting.
If You Want Help With Your Appeal
You may want help from a friend, lawyer or someone else. There are groups that can
find you a lawyer. Some can give you a free lawyer. We can give you the names of these
groups.
-
(1)
Choice 1 - your check until we decide your
Choice 2 - her check until we decide her
Choice 3 - his check until we decide his
-
(2)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(3)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(4)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(5)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(6)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(7)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(8)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(9)
Choice 1 - your
Choice 2 - her
Choice 3 - his
2907. Situation Where Used:
Appears only on the SSA-L8170. Individual is in current pay status.
How To Pay Us Back
There are two ways you can pay us back.
-
•
As we said earlier, we plan to hold back money from (1) SSI check. (2) (3) Ten percent is the most we can hold back without your consent. Contact us if you
want a different amount held back.
OR
-
•
Another way to pay us back is to send us a check or money order for the full amount
of (4) (5) overpayment of (6) . Paying us this way is voluntary. Make your check or money order out to the Social
Security Administration. Be sure to put (7) Social Security number on it. Please use the enclosed envelope to mail the check
or money order to us. Also, be sure to enclose the payment stub with your check or
money order.
Fill-ins:
-
(1)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(2)
Choice 1 - We'll hold back ($$$.¢¢) each month starting with (Month/Year) until you
have paid us back.
Choice 2 - We'll hold back ($$$.¢¢) each month starting with (Month /Year) until she
has paid us back.
Choice 3 - We'll hold back ($$$.¢¢) each month starting with (Month /Year) until he
has paid us back.
Choice 4 - We'll hold back ($$$.¢¢) in (Month/Year) to collect the overpayment.
Choice 5 - We'll hold back ($$$.¢¢) in (Month/Year) and ($$$ ¢¢) in Month/Year) to
collect the overpayment.
Choice 6 - We'll hold back your check each month starting with (Month/ Year) until
you have paid us back.
Choice 7 - We'll hold back her check each month starting with (Month/Year) until she
has paid us back.
Choice 8 - We'll hold back his check each month starting with (Month/Year) until he
has paid us back.
Choice 9 - We'll hold back your check for (Month/Year) to collect the overpayment.
Choice 10 - We'll hold back her check for (Month/Year) to collect the overpayment.
Choice 11 - We'll hold back his check for (Month/Year) to collect the overpayment.
Choice 12 - We'll hold back your checks for (Month/Year) and (Month/ Year) to collect
the overpayment.
Choice 13 - We'll hold back her checks for (Month/Year) and (Month/Year) to collect
the overpayment.
Choice 14 - We'll hold back his checks for (Month/Year) and (Month/Year) to collect
the overpayment.
Choice 15 - We'll hold back your check for (Month/Year) and ($$$.¢ ¢) in (Month/Year)
to collect the overpayment.
Choice 16 - We'll hold back her check for (Month/Year) and ¢) in (Month/Year) to collect
the overpayment.
Choice 17 - We'll hold back his check for (Month/Year) and ($$$.¢ ¢) in (Month/Year)
to collect the overpayment.
Choice 18 - We'll continue holding back your check each month until you have paid
back the old and the new overpayments.
Choice 19 - We'll continue holding back her check each month until she has paid back
the old and the new overpayments.
Choice 20 - We'll continue holding back his check each month until he has paid back
the old and the new overpayments.
Choice 21 - We'll continue holding back ($$$.¢¢) each month until you have paid back
the old and the new overpayments.
Choice 22 - We'll continue holding back ($$$.¢¢) each month until she has paid back
the old and the new overpayments.
Choice 23 - We'll continue holding back ($$$.¢¢) each month until he has paid back
the old and the new overpayments.
Choice 24 - We'll change the amount we hold back each month from ($$$. ¢ ¢) to ($$$.¢¢).
This will start in (Month/Year). It will continue until you have paid back the old
and the new overpayments.
Choice 25 - We'll change the amount we hold back each month from ($$$. ¢ ¢) to ($$$.¢¢).
This will start in (Month/Year). It will continue until she has paid back the old
and the new overpayments.
Choice 26 - We'll change the amount we hold back each month from ($$$. ¢ ¢) to ($$$.¢¢).
This will start in (Month/Year). It will continue until he has paid back the old and
the new overpayments.
Choice 27 - We will collect the advance payment first. Then, we will begin
Choice 28 - We will collect the advance payment first. Then we will begin collecting
the overpayment from her check.
Choice 29 - We will collect the advance payment first. Then, we will begin collecting
the overpayment from his check.
-
(3)
Choice 1 - This is not more than 10 percent of your total income.
Choice 2 - This is not more than 10 percent of her total income.
Choice 3 - This is not more than 10 percent of his total income.
Choice 4 - The amount of your SSI check is less than 10 percent of your total income.
Choice 5 - The amount of her SSI check is less than 10 percent of her total income.
Choice 6 - The amount of his SSI check is less than 10 percent of his total income.
Choice 7 - When we begin collecting the overpayment, we will collect no more than
10 percent of your total income.
Choice 8 - When we begin collecting the overpayment, we will collect no more than
10 percent of her total income.
Choice 9 - When we begin collecting the overpayment, we will collect no more than
10 percent of his total income.
-
(4)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(5)
Choice 1 - new
Choice 2 - Null
(6) $$$.¢¢
-
(7)
Choice 1 - your
Choice 2 - her
Choice 3 - his
2908. Situation Where Used:
Recipient is in a medical care facility where Medicaid pays for more than half the
cost of care and is currently receiving a monthly SSI check. We will not reduce her/his
check to recover the overpayment while in the medical care facility. This paragraph
appears only on the SSA-8170 and the SSA-L8171.
We Will Not Reduce (1) SSI Check
Usually when a person is getting an SSI check, we withhold money from the check to
repay an overpayment. But we will not do this while (2) :
-
•
In a medical care facility,
AND
-
•
Medicaid is paying for more than half the cost of (3) care.
If either of the above things change, and (4) still withholding money from (6) SSI check.
-
(1)
Choice 1 - Your
Choice 2 - Her
Choice 3 - His
-
(2)
Choice 1 - you are
Choice 2 - she is
Choice 3 - he is
-
(3)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(4)
Choice 1 - you
Choice 2 - she
Choice 3 - he
-
(5)
Choice 1 - have
Choice 2 - has
-
(6)
Choice 1 - your
Choice 2 - her
Choice 3 - his
2909. Situation Where Used:
and does not receive title II.
How To Pay Us Back
There are two ways you can pay us back.
-
•
You can send us a check or money order for the full amount of (1) (2) overpayment of (3) . Make your check or money order out to the Social Security Administration. Be sure
to put (4) Social Security number on it. Please use the enclosed envelope to mail the check
or money order to us. Also, be sure to enclose the payment stub with your check or
money order.
OR
-
•
If you can't send us the full amount now, send as much as you can. Then contact any
Social Security office. You can pay the rest of the money (5) by making monthly payments.
If you can't pay us in full, please contact us by (6) . You'll need to tell us how you plan to pay us back.
-
(1)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(2)
Choice 1 - new
Choice 2 - Null
-
-
(4)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(5)
Choice 1 - you owe
Choice 2 - she owes
Choice 3 - he owes
-
2910. Situation Where Used:
Appears only on the SSA-L8172. Individual is in nonpayment status but does receive
title II. Offers the option of recovery by making monthly payments or by cross-program
recovery.
How To Pay Us Back
There are three ways you can pay us back.
-
•
You can send us a check or money order for the full amount of (1) (2) overpayment of (3) . Make your check or money order out to the Social Security Administration. Be sure
to put (4) Social Security number on it. Please use the enclosed envelope to mail the check
or money order to us. Also, be sure to enclose the payment stub with your check or
money order.
OR
-
•
If you can't send us the full amount now, send as much as you can. Then contact any
Social Security office. You can pay the rest of the money (5) by making monthly payments.
OR
-
•
You can ask us to hold back part of (6) Social Security benefit until (7) paid us back. This way of paying us back is voluntary . If you ask us to do this you can tell us to stop whenever you want. (8) Social Security benefits won't change unless you choose to pay us back this way.
If you can't pay us in full, please contact us by (9) . You'll need to tell us how you plan to pay us back.
-
(1)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(2)
Choice 1 - new
Choice 2 - Null
-
-
(4)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(5)
Choice 1 - you owe
Choice 2 - she owes
Choice 3 - he owes
-
(6)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(7)
Choice 1 - you have
Choice 2 - she has
Choice 3 - he has
-
(8)
Choice 1 - Your
Choice 2 - Her
Choice 3 - His
-
2911. Situation Where Used:
Appeal rights. Appears only on the SSA-L8171 and SSA-L8172.
Do You Think We're Wrong?
If you think we're wrong, you have the right to appeal. We'll correct mistakes. We'll
look at any new facts you have.
-
•
You have 60 days to ask for an appeal.
-
•
The 60 days start the day after you get this letter.
-
•
You'll have to have a good reason for waiting more than 60 days to ask
-
•
To appeal, you must fill out a form called “Request for Reconsideration.” The form number is SSA-561. To get this form, contact one of our offices. We can
help you fill out the form.
How To Appeal
There are three ways to appeal. You can pick the one you want. If you meet with us in person, it may help us decide
(1) case .
-
•
Case Review . You have a right to review the facts in (2) file. You can give us more facts to add to (3) file. Then we'll decide (4) case again. You won't meet with the person who decides (5) case.
-
•
Informal Conference . You'll meet with the person who decides (6) case. You can tell that person why you think you're right. You can give us more facts
to help prove you're right. You can bring other people to help explain (7) case.
-
•
Formal Conference . This is a meeting like an informal conference. The difference is we can make people
come to help prove you're right. We can make them bring important papers about (8) case, even if they don't want to help you. You can question these people at your
meeting.
If You Want Help With Your Appeal
You may want help from a friend, lawyer or someone else. There are groups that give
you the names of these groups.
-
(1)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(2)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(3)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(4)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(5)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(6)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(7)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(8)
Choice 1 - your
Choice 2 - her
Choice 3 - his
2912. For Your Information(CAPTION)
2920. Enclosures:
—A Detailed Explanation of (1) Overpayment
—Payment Stub
—Refund Envelope
-
(1)
Choice 1 - Your
Choice 2 - Her
Choice 1 - His
2921. A Detailed Explanation of (1) Overpayment (CAPTION-TITLE)
-
(1)
Choice 1 - Your
Choice 2 - Her
Choice 3 - His
2922. Overpayment Summary(CAPTION)
2923. Situation Where Used:
All months in the overpayment period are new overpayments and are not windfall months.
(1) overpaid (2) . The following table shows how (3) payment changed each month. The first column lists the month(s) we paid (4) incorrectly. The next column shows the amount we paid (5) for each month. The last column, “Amount for Each Month,” shows the amount we should have paid (6) for each month.
(7)
| Month |
Amount We Paid Each Month |
Correct Amount for Each Month |
| (8) |
(9) |
(10) |
-
(1)
Choice 1 - You were
Choice 2 - She was
Choice 3 - He was
(2) $$$.¢¢
-
(3)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(4)
Choice 1 - you
Choice 2 - her
Choice 3 - him
-
(5)
Choice 1 - you
Choice 2 - her
Choice 3 - him
-
(6)
Choice 1 - you
Choice 2 - her
Choice 3 - him
-
(7)
Choice 1 - The SSI we paid you included some payments we made for your State. We show
your total SSI below, and then the part of this money that is from your State.
Choice 2 - The SSI we paid her included some payments we made for her State. We show
her total SSI below, and then the part of this money that is from her State.
Choice 3 - The SSI we paid him included some payments we made for his State. We show
his total SSI below, and then the part of this money that is from his State.
Choice 4 - Null
-
(8)
Choice 1 - (Month/Year)
Choice 2 - (Month/Year) and (Month/Year)
Choice 3 - (Month) through (Month/Year)
Choice 4 - Null
-
(9)
Choice 1 - $$$.¢¢
Choice 2 - $$$.¢¢($$$.¢¢from (State))
Choice 3 - Null
-
(10)
Choice 1 - $$$.¢¢
Choice 2 - $$$.¢¢($$$.¢¢from (State))
Choice 3 - Null
2924. Situation Where Used:
At least one of the overpayment months in the overpayment period has a prior overpayment (TOP)
on the old record and/or at least one of the overpayment months in the overpayment
period is in a title II windfall period.
(1) overpaid (2) . The following table shows how (3) payment changed each month. The first column lists the month(s) we paid (4) incorrectly. The next column shows the incorrect amount for each month. The last
column, “Correct Amount for Each Month,” shows the amount we should have paid (5) for each month.
(6)
| Month |
Incorrect Amount For Each Month |
Correct Amount For Each Month |
| (7) |
(8) |
(9) |
-
(1)
Choice 1 - You were
Choice 2 - She was
Choice 3 - He was
(2) $$$.¢¢
-
(3)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(4)
Choice 1 - you
Choice 2 - her
Choice 3 - him
-
(5)
Choice 1 - you
Choice 2 - her
Choice 3 - him
-
(6)
Choice 1 - The SSI we paid you included some payments we made for your State. We show
your total SSI below, and then the part of this money that is from your State.
Choice 2 - The SSI we paid her included some payments we made for her State. We show
her total SSI below, and then the part of this money that is from her State.
Choice 3 - The SSI we paid him included some payments we made for his State. We show
his total SSI below, and then the part of this money that is from his State.
Choice 4 - Null
-
(7)
Choice 1 - (Month/Year)
Choice 2 - (Month/Year) and (Month/Year)
Choice 3 - (Month/Year) through (Month/Year)
Choice 4 - Null
-
(8)
Choice 1 - $$$.¢¢
Choice 2 - $$$.¢¢($$$.¢¢from (State))
Choice 3 - Null
-
(9)
Choice 1 - $$$.¢¢
Choice 2 - $$$.¢¢($$$.¢¢from (State))
Choice 3 - Null
2925. Situation Where Used:
An overpayment addressed in a prior overpayment notice has an additional overpayment
computed.
This notice changes the decision we sent you before about (1) overpayment for (2) (3)
-
(1)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(2)
Choice 1 - (Month/Year)
Choice 2 - (Month/Year) through (Month/Year)
-
(3)
Choice 1 - ,
Choice 2 - and
Choice 3 - .
2926. Why (1) Overpaid(CAPTION)
-
(1)
Choice 1 - You Were
Choice 2 - She Was
Choice 3 - He Was
2927. Situation Where Used:
Recipient is overpaid due to an income change.
For the month(s) listed below, (1) income on our records was wrong. (2)
Under “Type of Income,” we list only the income which we corrected on our records. Under the column called
“Amount We Used,” we show the amount we used earlier to figure (3) payment. Under the column called “Correct Amount,” we show the amount we should have used to figure (4) payment. Please check that column against (5) records. If the amount is wrong, the amount of (6) overpayment is wrong.
| Month |
Amount We Used |
Correct Amount |
Type of |
| (7) |
(8) |
(9) |
(10) (11) |
| (12) |
|
|
|
-
(1)
Choice 1 - your
Choice 2 - her
Choice 3 - his
Choice 4 - the
-
(2)
Choice 1 - Because we didn't know about all your income, we paid you too much SSI.
Choice 2 - Because we didn't know about all her income, we paid her too much SSI.
Choice 3 - Because we didn't know about all his income, we paid him too much SSI.
Choice 4 - Because we didn't know about all the income, we paid you too much SSI.
Choice 5 - Because we didn't know about all the income, we paid her too much SSI.
Choice 6 - Because we didn't know about all the income, we paid him too much SSI.
Choice 7 - Null
-
(3)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(4)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(5)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(6)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(7)
Choice 1 - (Month/Year)
Choice 2 - (Month/Year) and (Month/Year)
Choice 3 - (Month/Year) through (Month/Year)
(8) $$$.¢¢
(9) $$$.¢¢
-
(10)
Choice 1 - Your
Choice 2 - Her
Choice 3 - His
Choice 4 - Your spouse's
Choice 5 - Her spouse's
Choice 6 - His spouse's
Choice 7 - Your parent's
Choice 8 - Her parent's
Choice 9 - His parent's
Choice 10 - Your parents'
Choice 11 - Her parents'
Choice 12 - His parents'
Choice 13 - (Name of essential person)'s
Choice 14 - (Name of essential persons)'
Choice 15 - Null
-
(11)
Choice 1 - Social Security benefits
Choice 2 - Black Lung benefits
Choice 3 - Veterans Administration benefits
Choice 4 - Railroad Retirement benefits
Choice 5 - Veterans Administration benefits based on need
Choice 6 - assistance payments based on need
Choice 7 - food, clothing or shelter
Choice 8 - Military pension
Choice 9 - civil service pension
Choice 10 - support from your parent
Choice 11 - support from her parent
Choice 12 - support from his parent
Choice 13 - pension from a former job
Choice 14 - worker's compensation
Choice 15 - interest, dividends, rents or royalties
Choice 16 - gifts, prizes, cash or special income
Choice 17 - Your sponsor's income which we count as yours
Choice 18 - Her sponsor's income which we count as hers
Choice 19 - His sponsor's income which we count as his
Choice 20 - Your sponsor's and sponsor's spouse's income which we count as yours
Choice 21 - Her sponsor's and sponsor's spouse's income which we count as hers
Choice 22 - His sponsor's and sponsor's spouse's income which we count as his
Choice 23 - wages
Choice 24 - income from being self-employed
Choice 25 - food and shelter in someone else's home or apartment
-
(12)
Choice 1 - We use income from 2 months earlier when we figure your SSI payment for
a month. You should remember this when comparing the above tables. For example, we
used income from (Month/Year) to figure your payment for (Month/Year).
Choice 2 - We use income from 2 months earlier when we figure her SSI payment for
a month. You should remember this when comparing the above tables. For example, we
used income from (Month/Year) to figure her payment for (Month/Year).
Choice 3 - We use income from 2 months earlier when we figure his SSI payment for
a month. You should remember this when comparing the above tables. For example, we
used income from (Month/Year) to figure his payment for (Month/Year).
Choice 4 - Null
2928. Situation Where Used:
an SSA-L8171.
(1) could not get SSI because all of these facts below were true.
• (2) in an institution run by the Federal, State, or local government. This includes some
hospitals, nursing homes, other care facilities or prisons.
AND
• (3) lived there at least 1 full month.
AND
•If (4) had Medicaid, it did not pay for more than half the cost of (5) care.
As a result, (6) overpaid for (7) . (8)
-
(1)
Choice 1 - You
Choice 2 - She
Choice 3 - He
-
(2)
Choice 1 - You were
Choice 2 - She was
Choice 3 - He was
-
(3)
Choice 1 - You
Choice 2 - She
Choice 3 - He
-
(4)
Choice 1 - you
Choice 2 - she
Choice 3 - he
-
(5)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(6)
Choice 1 - you were
Choice 2 - she was
Choice 3 - he was
-
(7)
Choice 1 - (Month/Year)
Choice 2 - (Month/Year) and (Month/Year)
Choice 3 - (Month/Year) through (Month/Year)
-
(8)
Choice 1 - You were eligible for SSI again on (Month/Day/Year), the day that you left
the institution.
Choice 2 - She was eligible for SSI again on (Month/Day/Year), the day that she left
the institution.
Choice 3 - He was eligible for SSI again on (Month/Day/Year), the day that he left
the institution.
Choice 4 - Null
2929. Situation Where Used:
Recipient was living outside the U.S. for a full calendar month
(1) could not get SSI because (2) outside the United States. For SSI, the United States is:
•One of the 50 States;
OR
•The District of Columbia;
OR
•The Northern Mariana Islands.
(3)
As a result, (4) overpaid for (5) .
-
(1)
Choice 1 - You
Choice 2 - She
Choice 3 - He
-
(2)
Choice 1 - you were
Choice 2 - she was
Choice 3 - he was
-
(3)
Choice 1 - You were not eligible for SSI again until the 31st day after you were back
in the United States. The 31st day was (Month/Day/Year).
Choice 2 - She was not eligible for SSI again until the 31st day after she was back
in the United States. The 31st day was (Month/Day/Year).
Choice 3 - He was not eligible for SSI again until the 31st was back in the United
States. The 31st day was (Month/Day/Year).
Choice 4 - Null
-
(4)
Choice 1 - you were
Choice 2 - she was
Choice 3 - he was
-
(5)
Choice 1 - (Month/Year)
Choice 2 - (Month/Year) and (Month/Year)
Choice 3 - Month/Year) through (Month/Year)
2930. Situation Where Used:
Recipient has excess resources.
(1) could not get SSI since the value of (2) resources was more than the SSI limit. As a result, (3) overpaid (4) (5) (6) (7) the limit on the value of the things (8) owned which we included as (9) resources (10) (11) .
(12) (13) (14) (15) .
Resources may include cash, money in bank accounts, stocks, bonds, land or housing
other than the home (16) in, certain kinds of life tell you which things we include as resources.
-
(1)
Choice 1 - You
Choice 2 - She
Choice 3 - He
-
(2)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(3)
Choice 1 - you were
Choice 2 - she was
Choice 3 - he was
-
(4)
Choice 1 - for (Month/Year)
Choice 2 - from (Month/Year) through (Month/Year)
Choice 3 - in (Month/Year)
-
(5)
Choice 1 - ,
Choice 2 - and
Choice 3 - .
-
(6)
Choice 1 - For (Month/Year)
Choice 2 - Before January 1985
Choice 3 - In (Month/Year) or In (Year)
Choice 4 - (Month/Year)
-
(7)
Choice 1 - ,
Choice 2 - and
Choice 3 - .
-
(8)
Choice 1 - you
Choice 2 - she
Choice 3 - he
Choice 4 - you and your spouse
Choice 5 - she and her spouse
Choice 6 - he and his spouse
Choice 7 - you and your parent
Choice 8 - she and her parent
Choice 9 - he and his parent
Choice 10 - you and your parents
Choice 11 - she and her parents
Choice 12 - he and his parents
Choice 13 - you and (Name of essential person)
Choice 14 - she and (Name of essential person)
Choice 15 - he and (Name of essential person)
Choice 16 - you, your spouse and (Name of essential person)
Choice 17 - she, her spouse and (Name of essential person)
Choice 18 - he, his spouse and (Name of essential person)
Choice 19 - you, your parent and (Name of essential person)
Choice 20 - she, her parent and (Name of essential person)
Choice 21 - he, his parent and (Name of essential person)
Choice 22 - you and your sponsor
Choice 23 - she and her sponsor
Choice 24 - he and his sponsor
Choice 25 - you, your sponsor and the spouse of your sponsor
Choice 26 - she, her sponsor and the spouse of her sponsor
Choice 27 - he, his sponsor and the spouse of his sponsor
Choice 28 - you, your spouse and your sponsor
Choice 29 - she, her spouse and her sponsor
Choice 30 - he, his spouse and his sponsor
Choice 31 - you, your spouse, your sponsor and the spouse of her sponsor
Choice 32 - she, her spouse, her sponsor and the spouse of her sponsor
Choice 33 - he, his spouse, his sponsor and the spouse of his sponsor
Choice 34 - you, your parent and your sponsor
Choice 35 - she, her parent and her sponsor
Choice 36 - he, his parent and his sponsor
Choice 37 - you, your parent, your sponsor and the spouse of your sponsor
Choice 38 - she, her parent, her sponsor and the spouse of her sponsor
Choice 39 - he, his parent, his sponsor and the spouse of his sponsor
Choice 40 - you, your parents and your sponsor
Choice 41 - she, her parents and her sponsor
Choice 42 - he, his parents and his sponsor
Choice 43 - you, your parents, your sponsor and the spouse of your sponsor
Choice 44 - she, her parents, her sponsor and the spouse of her sponsor
Choice 45 - he, his parents, his sponsor and the spouse of his sponsor
-
(9)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(10)
Choice 1 - is
Choice 2 - was
-
-
(12)
Choice 1 - For (Month/Year)
Choice 2 - In (Month/Year)
Choice 3 - (Month/Year)
Choice 4 - Null
-
(13)
Choice 1 - ,
Choice 2 - and
Choice 3 - Null
-
(14)
Choice 1 - the limit is
Choice 2 - the limit was
Choice 3 - Null
-
(15)
Choice 1 - $$$.¢¢
Choice 2 - Null
-
(16)
Choice 1 - you live
Choice 2 - she lives
Choice 3 - he lives
2931. Situation Where Used:
Recipient did not file the required application or take necessary steps to obtain
other benefits or payments.
We wrote to you about filing for money (1) may be able to get. We told you that (2) must file for this money in order to get SSI.
(3) did not file within 30 days after we told (4) to file. Because of this, (5) could not get SSI starting with (6) .
As a result, (7) overpaid for (8) . (9)
-
(1)
Choice 1 - you
Choice 2 - she
Choice 3 - he
-
(2)
Choice 1 - you
Choice 2 - she
Choice 3 - he
-
(3)
Choice 1 - You
Choice 2 - She
Choice 3 - He
-
(4)
Choice 1 - you
Choice 2 - her
Choice 3 - him
-
(5)
Choice 1 - you
Choice 2 - she
Choice 3 - he
-
-
(7)
Choice 1 - you were
Choice 2 - she was
Choice 3 - he was
-
(8)
Choice 1 - (Month/Year)
Choice 2 - (Month/Year) and (Month/Year)
Choice 3 - (Month/Year) through (Month/Year)
-
(9)
Choice 1 - You were eligible for SSI again on (Month/Day/Year), the day you filed
for this money.
Choice 2 - She was eligible for SSI again on (Month/Day/Year), the day she filed for
this money.
Choice 3 - He was eligible for SSI again on (Month/Day/Year), the day he filed for
this money.
Choice 4 - Null
2932. Situation Where Used:
Recipient's disability or blindness ceased.
(1) could not get SSI after (2) . (3) eligibility for payment based on (4) ended on (5) .
As a result, (6) overpaid for (7) .
-
(1)
Choice 1 - You
Choice 2 - She
Choice 3 - He
-
-
(3)
Choice 1 - Your
Choice 2 - Her
Choice 3 - His
-
(4)
Choice 1 - disability
Choice 2 - blindness
-
-
(6)
Choice 1 - you were
Choice 2 - she was
Choice 3 - he was
-
(7)
Choice 1 - (Month/Year)
Choice 2 - (Month/Year) and (Month/Year)
Choice 3 - (Month/Year) through (Month/Year)
2933. Situation Where Used:
Reversal of a disability decision or a blindness decision retroactive to initial eligibility.
(1) could not get SSI because (2) not (3) .
As a result, (4) overpaid for (5) .
-
(1)
Choice 1 - You
Choice 2 - She
Choice 3 - He
-
(2)
Choice 1 - you were
Choice 2 - she was
Choice 3 - he was
-
(3)
Choice 1 - disabled
Choice 2 - blind
-
(4)
Choice 1 - you were
Choice 2 - she was
Choice 3 - he was
-
(5)
Choice 1 - (Month/Year)
Choice 2 - (Month/Year) and (Month/Year)
Choice 3 - (Month/Year) through (Month/Year)
2935. Situation Where Used:
Recipient is in noncompliance with treatment requirement for drug addiction and alcoholism.
(1) disability is based in part on (2) . (3) must accept treatment for this problem. Since (4) refused treatment, (5) could not get SSI starting with (6) .
As a result, (7) overpaid for (8) . (9)
-
(1)
Choice 1 - Your
Choice 2 - Her
Choice 3 - His
-
(2)
Choice 1 - drug addiction
Choice 2 - alcoholism
Choice 3 - drug addiction and alcoholism
-
(3)
Choice 1 - You
Choice 2 - She
Choice 3 - He
-
(4)
Choice 1 - you
Choice 2 - she
Choice 3 - he
-
(5)
Choice 1 - you
Choice 2 - she
Choice 3 - he
-
-
(7)
Choice 1 - you were
Choice 2 - she was
Choice 3 - he was
-
(8)
Choice 1 - (Month/Year)
Choice 2 - (Month/Year) and (Month/Year)
Choice 3 - (Month/Year) through (Month/Year)
-
(9)
Choice 1 - You were eligible for SSI again on (Month/Day/Year), the day you started
treatment.
Choice 2 - She was eligible for SSI again on (Month/Day/Year), the day she started
treatment.
Choice 3 - He was eligible for SSI again on (Month/Day/Year), the day he started treatment.
Choice 4 - Null
2936. Situation Where Used:
Recipient was not a citizen or legal alien.
(1) could not get SSI because:
• (2) not a citizen of the U.S.,
OR
•If (3) from a foreign country, the U.S. Immigration and Naturalization Service (INS) did
not plan to let (4) stay in the U.S.
As a result, (5) overpaid for (6) . (7)
-
(1)
Choice 1 - You
Choice 2 - She
Choice 3 - He
-
(2)
Choice 1 - You were
Choice 2 - She was
Choice 3 - He was
-
(3)
Choice 1 - you are
Choice 2 - she is
Choice 3 - he is
-
(4)
Choice 1 - you
Choice 2 - her
Choice 3 - him
-
(5)
Choice 1 - you were
Choice 2 - she was
Choice 3 - he was
-
(6)
Choice 1 - (Month/Year)
Choice 2 - (Month/Year) and (Month/Year)
Choice 3 - (Month/Year) through (Month/Year)
-
(7)
Choice 1 - You were eligible for SSI on (Month/Day/Year), the day you became a citizen,
or INS decided to let you stay in the U.S.
Choice 2 - She was eligible for SSI on (Month/Day/Year), the day she became a citizen
or INS decided to let her stay in the U.S.
Choice 3 - He was eligible for SSI on (Month/Day/Year), the day he became a citizen
or INS decided to let him stay in the U.S.
Choice 4 - Null
2937. Situation Where Used:
Recipient requests termination of eligibility effective for a month for which he received
payment and such payment was not returned.
(1) asked us to stop sending SSI checks (2) . (3) agreed to return any check (4) received after (5) .
that month, (7) overpaid for (8) .
-
(1)
Choice 1 - You
Choice 2 - She
Choice 3 - He
-
(2)
Choice 1 - to you
Choice 2 - to her
Choice 3 - to him
Choice 4 - for her
Choice 5 - for him
-
(3)
Choice 1 - You
Choice 2 - She
Choice 3 - He
-
(4)
Choice 1 - you
Choice 2 - she
Choice 3 - he
-
-
(6)
Choice 1 - you
Choice 2 - she
Choice 3 - he
-
(7)
Choice 1 - you were
Choice 2 - she was
Choice 3 - he was
-
(8)
Choice 1 - (Month/Year)
Choice 2 - (Month/Year) and (Month/Year)
Choice 3 - (Month/Year) through (Month/Year)
2938. Situation Where Used:
Recipient is in a medical facility where Medicaid pays for more than half the cost
of the care.
NOTE: OBSOLETE—(Replaced by 2939, May 31, 1988.)
(1) could not get more than $25 SSI money because all of the facts below were true.
• (2) in a medical care facility, like a hospital or nursing home.
AND
• (3) lived there for the full month.
AND
•Medicaid paid for more than half the cost of (4) care.
Also, if there was income on (5) record other than SSI, (6) might get less than $25 SSI money.
As a result, (7) overpaid for (8) (9)
-
(1)
Choice 1 - You
Choice 2 - She
Choice 3 - He
-
(2)
Choice 1 - You were
Choice 3 - She was
Choice 4 - He was
-
(3)
Choice 1 - You
Choice 2 - She
Choice 3 - He
-
(4)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(5)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(6)
Choice 1 - you
Choice 2 - she
Choice 3 - he
-
(7)
Choice 1 - you were
Choice 2 - she was
Choice 3 - he was
-
(8)
Choice 1 - (Month/Year)
Choice 2 - (Month/Year) through (Month/Year)
-
(9)
Choice 1 - ,
Choice 2 - and
Choice 3 - .
2939. (1) could not get more than (2) because all of the facts below were true.
• (3) in a medical care facility, like a hospital or a nursing home.
• (4) lived there for the full month.
•Medicaid paid for more than half the cost of (5) care.
Also, if there was income on (6) record other than SSI, (7) might get less than (8) . As a result, (9) overpaid for (10) (11)
-
(1)
Choice 1 - You
Choice 2 - She
Choice 3 - He
-
(2)
Choice 1 - $25 in SSI money
Choice 2 - $25 in SSI money for months before July 1988 or more than $30 SSI money
for months July 1988 on
Choice 3 - $30 in SSI money
-
(3)
Choice 1 - You were
Choice 2 - She was
Choice 3 - He was
-
(4)
Choice 1 - You
Choice 2 - She
Choice 3 - He
-
(5)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(6)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(7)
Choice 1 - you
Choice 2 - she
Choice 3 - he
-
(8)
Choice 1 - $25 in SSI money
Choice 2 - $25 in SSI money for months before July 1988 or less than $30 SSI money
for months July 1988 on
Choice 3 - $30 in SSI money
-
(9)
Choice 1 - you were
Choice 2 - she was
Choice 3 - he was
-
(10)
Choice 1 - (Month/Year)
Choice 2 - (Month/Year) through (Month/Year)
-
(11)
Choice 1 -,
Choice 2 - and
Choice 3 - .
2940. PAYMENT STUB
Please Cut Along The Dotted Line
-
•
Please cut along the dotted line. Return the bottom portion of the stub with your
payment.
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•
Please use the enclosed envelope to mail your payment to us.
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Be sure to tell us if you've changed your address.
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Do not send cash or stamps.
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| (1) |
•Make your check or money order payable to: |
| Administration |
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| Please show any change of address below |
•Print this on your check or money order: (3) |
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(3)
Social Security Number and type of SSI Record