TN 15 (02-90)
NL 00804.215 Withdrawal and Voluntary Termination
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Withdrawal prior to adjudication. (Used with paragraph 1503.)
We have approved (1) request for withdrawal of (2) application for Supplemental Security Income payments. Therefore, we have not determined
whether or not (3) eligible to receive Supplemental Security Income payments.
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(1)
Choice 1 - your
Choice 2 - her
Choice 3 - his
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(2)
Choice 1 - your
Choice 2 - her
Choice 3 - his
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(3)
Choice 1 - you are
Choice 2 - she is
Choice 3 - he is
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IC: Withdrawal prior to adjudication. (Used with paragraph 1500.)
PE: Request for termination of eligibility approved. (Used with paragraph 2470.)
If (1) Supplemental Security Income, (2) should tell us no later than 60 days after the date of this notice. If (3) mind after that please contact us immediately to file a new application since, after
that time, we will not be able to make payment for any month before the month in which
(4) .
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(1)
Choice 1 - you change your mind and decide you want
Choice 2 - she changes her mind and decides she wants
Choice 3 - he changes his mind and decides he wants
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(2)
Choice 1 - you
Choice 2 - she
Choice 3 - he
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(3)
Choice 1 - you change your
Choice 2 - she changes her
Choice 3 - he changes his
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(4)
Choice 1 - you apply
Choice 2 - she applies
Choice 3 - he applies
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Individual residing in State for which Social Security Administration administers
optional supplementation program. Individual waives State supplement.
Based on your request, we will no longer send (1) money from the (2) beginning (3) . If (4) to receive this money, you should contact any Social Security office.
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(1)
Choice 1 - you
Choice 2 - her
Choice 3 - him
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(2)
Choice 1 - State of (State Name)
Choice 2 - District of Columbia
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(4)
Choice 1 - you later decide you wish
Choice 2 - she later decides she wishes
Choice 3 - he later decides he wishes
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Recipient's request for termination of eligibility approved. (Used with paragraph
1503.)
Based on your request, we (1) (2) eligibility for Supplemental Security Income payments beginning (3) . (4)
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(1)
Choice 1 - have terminated
Choice 2 - will terminate
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(2)
Choice 1 - your
Choice 2 - her
Choice 3 - his
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(4)
Choice 1 - We will no longer send you checks.
Choice 2 - We will no longer send her checks.
Choice 3 - We will no longer send him checks.
Choice 4 - Null
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Recipient requests termination of eligibility effective for a month for which he/she
received payment and such payment was not returned.
You asked that (1) eligibility for Supplemental Security Income be terminated beginning (2) . We cannot terminate (3) eligibility that month unless you pay back the (4) we sent (5) (6) . If you repay this money, we will terminate (7) eligibility back to (8) . To repay the money, please mail a check or money order for this amount made payable
to the Social Security Administration, (9) , to (10) Social Security office. You should also return to (11) Social Security office any Supplemental Security Income checks (12) after receiving this notice.
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(1)
Choice 1 - your
Choice 2 - her
Choice 3 - his
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(3)
Choice 1 - your
Choice 2 - her
Choice 3 - his
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(5)
Choice 1 - you
Choice 2 - her
Choice 3 - him
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(6)
Choice 1 - for (Month/Year)
Choice 2 - for (Month/Year) through (Month/Year)
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(7)
Choice 1 - your
Choice 2 - her
Choice 3 - his
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(9)
(Recipient's Social Security Number)
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(10)
Choice 1 - your
Choice 2 - her
Choice 3 - his
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(11)
Choice 1 - your
Choice 2 - her
Choice 3 - his
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(12)
Choice 1 - you get
Choice 2 - she gets
Choice 3 - he gets
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Recipient decides (within the 60 day grace period) not to terminate eligibility.
Because you changed your mind and do not want to (1) for Supplemental Security Income, (2) (3) (4) .
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(1)
Choice 1 - terminate your eligibility
Choice 2 - terminate her eligibility
Choice 3 - terminate his eligibility
Choice 4 - withdraw your application
Choice 5 - withdraw her application
Choice 6 - withdraw his application
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(2)
Choice 1 - we will begin sending your payments right away. You will also receive any
payments you returned
Choice 2 - we will begin sending her payments right away. You will also receive any
payments that were returned
Choice 3 - we will begin sending his payments right away. You will also receive any
payments that were returned
Choice 4 - we can pay you
Choice 5 - we can pay her
Choice 6 - we can pay him
Choice 7 - we have reviewed your claim. Based on the information available to us,
we find that you are not eligible for payment at this time.
Choice 8 - we have reviewed her claim. Based on the information available to us, we
find that she is not eligible for payment at this time.
Choice 9 - we have reviewed his claim. Based on the information available to us, we
find that he is not eligible for payment at this time.
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(3)
Choice 1 - for (Month/Year)
Choice 2 - for (Month/Year) through (Month/Year)
Choice 3 - for (Month/Year) on
Choice 4 - Null
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(4)
Choice 1 - ,
Choice 2 - and
Choice 3 - .
Choice 4 - Null
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Recipient requested withdrawal of application and refunded all payments received or
total payments can be withheld from future title II benefits, or no payments were
made.
You asked that (1) application for Supplemental Security Income be withdrawn. (2) we have approved (3) request. (4)
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(1)
Choice 1 - your
Choice 2 - her
Choice 3 - his
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(2)
Choice 1 - Since you paid back the money we sent you,
Choice 2 - Since you paid back the money we sent her,
Choice 3 - Since you paid back the money we sent him,
Choice 4 - Since you asked us to withhold from your Social Security benefits an amount
to repay the Supplemental Security Income payment we sent you,
Choice 5 - Since you asked us to withhold from your Social Security benefits an amount
to repay the Supplemental Security Income payment we sent her,
Choice 6 - Since you asked us to withhold from your Social Security benefits an amount
to repay the Supplemental Security Income payment we sent him,
Choice 7 - Null
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(3)
Choice 1 - your
Choice 2 - the
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(4)
Choice 1 - No more checks will be sent to you.
Choice 2 - No more checks will be sent to her.
Choice 3 - No more checks will be sent to him.
Choice 4 - Null
Manual Paragraphs
Withdrawal and Voluntary Termination
WDWM50. Situation Where Used:
Withdrawal requested after payment—refund requested.
(1) asked us to withdraw (2) application for Supplemental Security Income checks. We cannot do this until (3) back the (4) we have already sent to (5) . (6) must also return to (7) Social Security office any Supplemental Security Income checks (8) from now on. As soon as (9) this money, (10) application will be withdrawn. If (11) done so already, please mail a check or money order to (12) Social Security office. Make it payable to the Social Security Administration. Do
not mail cash to the Social Security office.
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(1)
Choice 1 - You have
Choice 2 - (Name of Claimant) has
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(2)
Choice 1 - your
Choice 2 - her
Choice 3 - his
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(3)
Choice 1 - you pay
Choice 2 - she pays
Choice 3 - he pays
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(5)
Choice 1 - you
Choice 2 - her
Choice 3 - him
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(6)
Choice 1 - You
Choice 2 - She
Choice 3 - He
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(7)
Choice 1 - your
Choice 2 - her
Choice 3 - his
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(8)
Choice 1 - you get
Choice 2 - she gets
Choice 3 - he gets
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(9)
Choice 1 - you repay
Choice 2 - she repays
Choice 3 - he repays
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(10)
Choice 1 - your
Choice 2 - her
Choice 3 - his
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(11)
Choice 1 - you have not
Choice 2 - she has not
Choice 3 - he has not
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(12)
Choice 1 - your
Choice 2 - her
Choice 3 - his