DI 12095.125 Model Language SSI Notice of Planned Action - DA&A Provisions Apply
Model Language-SSI Notice of Planned Action to a Recipient from DO Informing Him of
DA&A Provisions (to be used following CDI determination of continuance where DA&A
requirements now Imposed but not previously applicab1e)
Supplemental Security Income
Notice of Planned Action
Department of Health and Human Services
Social Security Administration
Social Security Number:
Your payments (or those of the individual named above) will be changed as follows:
Your payment will be stopped effective (date) .
You have been notified that (drug addiction) (alcoholism) 1 / contributes to the finding that you are still disabled. Under the law, a disabled
person who is medically determined to be a drug addict or alcoholic must receive his
supplemental security income payments through another person on his behalf. In addition,
he must undergo any appropriate treatment for his condition as a drug addict or alcoholic,
if such treatment is available, in order to be eligible for payments.
We want to discuss these provisions with you in greater detail and to obtain information
from you which, will assist us in selecting a representative payee to receive your
supplemental security income payments on your behalf. A decision will be made later
as to whether appropriate treatment is available. Please contact this office within
10 days after receipt of this notice to arrange for an appointment. If you phone,
please have this notice nearby so that you may refer to it. Please bring it with you
if you visit the office.
If you do not provide information to assist us in selecting a representative payee
to receive your supplemental security income payments for you, your payments will
be stopped effective (date) (unless we otherwise have sufficient information to select
a payee for you). If you believe the determination that (drug addiction) (alcoholism)
1/ contributes to the finding that you are disabled is not correct, you may request
reconsideration as explained on the reverse of the notice.
1/ Use term(s) that applies
We won't change your check if you appeal within 10 days after getting this notice.
TURN THIS OVER if you think we're wrong
YOUR RIGHT TO APPEAL
Do you think we're wrong? If so, you have the right to appeal. If you appeal, we'll
review our decision. We'll change mistakes. Do you have other questions? If so, get
in touch with us. Please bring this notice with you if you come to a Social Security
You have 60 DAYS TO APPEAL after you get this notice. If you wait more than 60 days, you must have a good excuse.
APPEAL IN 10 DAYS TO KEEP GETTING YOUR SAME CHECK
We won't change your check if you appeal within 10 days after getting this notice. You'll keep getting your same check until we decide your
appeal. If you lose your appeal, you might have to pay some or all of this money back.
HOW TO APPEAL
There are three different ways to appeal. You can pick the one you want. The people
in our offices can explain how these appeals work. You can have a lawyer, friend,
or someone else help you with your appeal.
Here are the three ways to appeal:
You can give us more facts to add to your file. Then we'll decide your case again.
You don't meet with the person who decides your case.
You'll meet with the person who will decide 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.
This is a meeting like an informal conference. Plus, we can make people come to help
prove you're right. We can make them bring important papers about your case. We can
do this even if they don't want to help you. You can question these people at your
To appeal, you must fill out a form at one of our offices. It is called a Request
for Reconsideration, SSA-561-U2. On the form, YOU PICK THE KIND OF APPEAL YOU WANT. We'll help you fill it out.
There are groups that can help you with your appeal. Some can give you a free lawyer.
We can give you names of these groups.