Effective Dates: 08/24/2023 - Present Previous | Next

TN 59 (08-23)

GN 02604.455 Title XVI Supplemental Security Income Notices

A. Supplemental security income (SSI) notices

The notice language for administrative sanctions is on the Document Processing System (DPS).

1. Person not in pay status and a sanction applies

When we deny a person SSI and subsequently find them subject to an administrative sanction:

  1. a. 

    Include the applicable language with the appropriate fill-in choices on form notice SSA-L8165-U2, Important Information (see in GN 02604.455B).

  2. b. 

    Use the caption, “Why We Will Not Pay You/Name of Claimant”

  3. c. 

    Include the appeals language in GN 02604.455C.

2. Recipient in pay status and an administrative sanction applies

When we find a recipient in payment status subject to an administrative sanction:

  1. a. 

    Include the applicable language with the appropriate fill-in choices on form notice SSA-L8165-U2 Important Information (see GN 02604.455B).

  2. b. 

    Use the caption, “Why Your/Name of recipient (possessive form) Payments Are Stopping”

  3. c. 

    Include the appeals language in GN 02604.455C.

B. Language to explain administrative sanctions to the beneficiary

Use the language in this subsection to explain administrative sanctions.

______(1)________

Under SSI rules, we will not pay a person SSI payments for a certain period of time if that person:

  • •

    made a statement or presented a material fact that the person knew or should have known was false or misleading, and the information was for use in deciding eligibility or payment amounts; or

  • •

    omitted material facts that the person knew or should have known we needed when we decided eligibility or payment amounts; or

  • •

    failed to report a material fact that could have affected eligibility or payment amounts if the person knew or should have known that failing to disclose the information would be misleading.

When we do not pay the person, we call this a penalty. The first time we apply a penalty we will not make payments for 6 months, the second time we will not make payments for 12 months, and for any time after that we will not make payments for 24 months.

____(2)______

____(3)______

____(4)______

We have decided __(5)__ ___(6)____ as described above.

___(7)____

___(8)____

Fill-ins:

Field Number

Choice

Choice Content

1.

Choice 1:

We are writing to tell you that, if (you become/name of claimant becomes) eligible for Supplemental Security Income (SSI) payments in the future, (you/she/he) will not receive all payments due. The rest of this letter will give you more information.

 

Choice 2:

We are writing to tell you that, even though (you are/name of recipient is) eligible for Supplemental Security Income (SSI) payments, we will not pay (you/her/him) for MM/YY through MM/YY. The rest of this letter will give you more information.

2.

Choice 1:

This penalty applies to Social Security and Supplemental Security Income payments. We will send a separate notice about (your/her/his) Social Security payments (you/she/he) filed for or are already due.

 

Choice 2:

Null

3.

Choice 1:

(Your/Her/His) eligibility to Medicaid is not affected by this penalty.

 

Choice 2:

Null

4.

Choice 1:

Payments to (your/her/his) spouse are not affected by this penalty.

 

Choice 2:

Null

5.

Choice 1:

you

 

Choice 2:

she

 

Choice 3:

he

6.

Choice 1:

made a statement or presented material facts

 

Choice 2:

omitted material facts

 

Choice 3:

failed to report material facts

7.

Description of why we decided on the penalty

 

8.

Choice 1:

We will not pay (you/her/him) as described above if (you become/she becomes/he becomes) eligible for Supplemental Security Income and/or Social Security benefits in the future.

 

Choice 2:

Therefore, we will not pay (you/her/him) for MM/YY through MM/YY. If (you meet/she meets/he meets) all SSI eligibility requirements beginning MM/YY, we will start payment again.

C. Appeals language for administrative sanction cases

Use the appeals language in this subsection for administrative sanction cases.

If You Disagree With The Decision

If you disagree with the decision, you have the right to appeal. We will review your case and consider 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. We assume you got this letter 5 days after the date on it unless you show us that you did not get it within the 5-day period.

  • •

    You must 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 your case.

  • •

    Case Review. You have a right to review the facts in your file. You can give us more facts to add to your file. Then we'll decide your case again. You won't meet with the person who decides your case.

  • •

    Informal Conference. You'll meet with the person who decides your 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 your 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 your 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 can have a friend, lawyer, or someone else help you. There are groups that can help you find a lawyer or give you free legal services if you qualify. There are also lawyers who do not charge unless you win your appeal. Your local Social Security office has a list of groups that can help you with your appeal.

If you get someone to help you, you should let us know. If you hire someone, we must approve the fee before they can collect it.

D. Sample Title XVI notices

Below are sample Title XVI administrative sanction notices.

1. Recipient not in pay and a sanction applies

 

  

Social Security Administration

Supplemental Security Income

  

Important Information

  

                                                                                Office Address:

  

                                                                                Social Security Number:

  

                                                                                Date:

  

  

 

CLAIMANT'S NAME

STREET ADDRESS

CITY/STATE ZIP CODE

  

                                                                           Type of Payment

                                                                           Individual--Disabled

  

We are writing to tell you that, if you become eligible for Supplemental Security Income (SSI) payments in the future, you will not receive all payments due. The rest of this letter will give you more information.

Why We Will Not Pay You

Under SSI rules, we will not pay a person SSI payments for a certain period of time if that person:

  • •

    made a statement or presented a material fact that the person knew or should have known was false or misleading, and the information was for use in deciding eligibility or payment amounts; or

  • •

    omitted material facts that the person knew or should have known we needed when we decided eligibility or payment amounts; or

  • •

    failed to report a material fact that could have affected eligibility or payment amounts if the person knew or should have known that failing to disclose the information would be misleading.

  

 

 

SSA-L8165

999-99-9999

00/00/00                                                                                           Page 2

  

  

When we do not pay the person, we call this a penalty. The first time we apply a penalty we will not make payments for 6 months, the second time we will not make payments for 12 months, and for any time after that we will not make payments for 24 months.

This penalty applies to Social Security and Supplemental Security Income payments. We will send a separate notice about your Social Security payments you filed for or are already due.

Payments to your spouse are not affected by this penalty.

We have decided you made a statement or presented material facts as described above. You stated you only had one bank account with a total of $1,000. You did not tell us about the other bank account you had with a total of $15,000.

We will not pay you as described above if you become eligible for Supplemental Security Income and/or Social Security benefits in the future.

If You Disagree With The Decision

If you disagree with the decision, you have the right to appeal. We will review your case and consider 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. We assume you got this letter 5 days after the date on it unless you show us that you did not get it within the 5-day period.

  • •

    You must 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.

  

 

 

SSA-L8165

999-99-9999

00/00/00                                                                                                Page 3

  

 

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 your case.

  • •

    Case Review. You have a right to review the facts in your file. You can give us more facts to add to your file. Then we'll decide your case again. You won't meet with the person who decides your case.

  • •

    Informal Conference. You'll meet with the person who decides your 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 your 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 your 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 can have a friend, lawyer, or someone else help you. There are groups that can help you find a lawyer or give you free legal services if you qualify. There are also lawyers who do not charge unless you win your appeal. Your local Social Security office has a list of groups that can help you with your appeal.

If you get someone to help you, you should let us know. If you hire someone, we must approve the fee before he or she can collect it.

If You Have Any Questions

For general information about Social Security we invite you to visit our website at www.socialsecurity.gov on the Internet. For general questions and specific questions about your case, you may call us toll-free at 1-800-772-1213, or call your local Social Security office at 000-00-0000. We can answer most questions over the phone. If you are deaf or hard of hearing, you may call our TTY/TDD number 000-00-0000. If you do call or visit an office, please have this letter with you. It will help us answer your questions.

  

  

 

 

                                                                                  Social Security Administration

  

SSA-L8165

2. Recipient in current pay status and an administrative sanction applies

 

Social Security Administration

Supplemental Security Income

  

Important Information

                                                                                           Office Address:

  

                                                                                           Social Security Number:

  

                                                                                           Date:

  

  

CLAIMANT'S NAME

STREET ADDRESS

CITY/STATE ZIP CODE

  

                                                                                         Type of Payment

                                                                                         Individual--Disabled

  

We are writing to tell you that, even though you are eligible for Supplemental Security Income (SSI) payments, we will not pay you for July 2001 through December 2001. The rest of this letter will give you more information.

Information About Your Payments

Under SSI rules, we will not pay a person SSI payments for a certain period of time if that person:

  • •

    made a statement or presented a material fact that the person knew or should have known was false or misleading, and the information was for use in deciding eligibility or payment amounts; or

  • •

    omitted material facts that the person knew or should have known we needed when we decided eligibility or payment amounts; or

  • •

    failed to report a material fact that could have affected eligibility or payment amounts if the person knew or should have known that failing to disclose the information would be misleading.

  

 

 

SSA-L8165

999-99-99999

00/00/00                                                                                                Page 2

  

  

 

 

When we do not pay the person, we call this a penalty. The first time we apply a penalty we will not make payments for 6 months, the second time we will not make payments for 12 months, and for any time after that we will not make payments for 24 months.

Your eligibility to Medicaid is not affected by this penalty.

We have decided you made a statement or presented material facts as described above. You stated you only had one bank account with a total of $1,000. You did not tell us about the other bank account you had with a total of $15,000.

Therefore, we will not pay you from July 2001 through December 2001. If you meet all SSI eligibility requirements beginning January 2002, we will resume your payments.

If You Disagree With The Decision

If you disagree with the decision, you have the right to appeal. We will review your case and consider 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. We assume you got this letter 5 days after the date on it unless you show us that you did not get it within the 5-day period.

  • •

    You must 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.

  

 

 

 

SSA-L8165

999-99-9999

00/00/00                                                                                                              Page 3

  

 

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 your case.

  • •

    Case Review. You have a right to review the facts in your file. You can give us more facts to add to your file. Then we'll decide your case again. You won't meet with the person who decides your case.

  • •

    Informal Conference. You'll meet with the person who decides your 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 your 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 your 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 can have a friend, lawyer, or someone else help you. There are groups that can help you find a lawyer or give you free legal services if you qualify. There are also lawyers who do not charge unless you win your appeal. Your local Social Security office has a list of groups that can help you with your appeal.

If you get someone to help you, you should let us know. If you hire someone, we must approve the fee before he or she can collect it.

If You Have Any Questions

For general information about Social Security we invite you to visit our website at www.socialsecurity.gov on the Internet. For general questions and specific questions about your case, you may call us toll-free at 1-800-772-1213, or call your local Social Security office at 000-00-0000. We can answer most questions over the phone. If you are deaf or hard of hearing, you may call our TTY/TDD number 000-00-0000. If you do call or visit an office, please have this letter with you. It will help us answer your questions.

  

  

  

 

                                                                                       Social Security Administration

  

SSA-L8165

 

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0202604455
GN 02604.455 - Title XVI Supplemental Security Income Notices - 08/24/2023
Batch run: 08/24/2023
Rev:08/24/2023