Social Security Administration
Supplemental Security Income
Social Security Number:
CITY/STATE ZIP CODE
Type of Payment
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
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
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
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
Social Security Administration