NL 00804.700 List of Sample SSI Notices

This section contains examples of notices for specific situations. In some samples, specific language is highlighted to show how it may be used in a notice. However, since there are many variables in SSI notices, e.g., representative payees, eligibility factors, etc., do not send the notices represented here to the public. Instead, use NL 00802 and

NL 00803 for additional paragraphs tailored to the specific situation for which you are sending the notice.

Notice Number	Form	Highlighted Paragraph	Situation
1	SSA-L8155-U2	SUSM50 SUSM51 SUSM52	We are suspending the following month's benefit by imputing N20 (failure to cooperate) during the Goldberg/Kelly temporary period. (See SI 02301.235G.2.) NOTE: We do not use the payment chart (paragraph 2016) when the only change the notice addresses is N20 for the current computation month (CCM).
2	SSA-L8166-U2	PENM50 PENM52	Penalty Notice—We are withholding a penalty ($25) for the first time. (See SI 02301.110E.1.)
3	SSA-L8151-U2	PMTM01	N05 Unconfirmed Eligibility—Use of N05 for past nonpay months in reinstatement case. (See SI 02301.220C.)
4	SSA-L8165-U2	GBKM06 GBKM08	Correcting Multiple Payments (including payments over the payment ceiling. (See SI 02301.315G, Example 1.)
5	SSA-L8165-U2	GBKM07 GBKM08	Correcting Payments Over the Payment Ceiling (See SI 02301.315G, Example 2.)
6	SSA-L8151-U2	COLM50	Correct Increased PPL During an Appeal—COLA increase (See SI 02301.325D.)
7	SSA-L8155-U2	COLM50	Correct Reduced PPL During an Appeal—COLA decrease (See SI 02301.325D.)