TN 5 (02-99)

SI 00502.170 Exhibit Notice - Nonqualified Alien Suspension Notice - 1619(B) Version

Social Security Administration
Supplemental Security Income
Notice of Planned Action

Date:
Claim Number:

Recipient's Name
Street Address
City/State/Zip Code

Type of Payment:

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  You Will Lose Your Special SSI Eligibility Status on               

  We plan to stop your special Supplemental Security Income (SSI) eligibility status beginning                . This special eligibility status means we have been keeping your SSI case active even though we had stopped paying you SSI. We did this because your earnings were the only reason we could not pay you. Under special SSI rules, we told your State your case was still active. We did this so the State could continue to give you Medicaid, if you met their rules for Medicaid.

  We urge you to read this entire letter, including the information about appeal rights and the information about Medicaid eligibility. If you have any questions, you may call us toll-free at 1-800-772-1213, or call your local office at the number shown on the last page of this notice.

Why You are Losing Your Special SSI Eligibility Status

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  You will lose your special SSI eligibility status because we do not have proof in our records that you are a United States (U.S.) citizen or national or in one of the alien eligibility categories shown below.

Alien Eligibility Categories

Persons who are lawfully residing in the U.S. and were receiving SSI benefits on August 22, 1996 can continue to receive benefits if they are in one of the following alien eligibility categories:

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  lawfully admitted for permanent residence under the Immigration and Nationality Act (INA);

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  an American Indian born outside the U.S. who is under section 289 of the INA or who is a member of a federally recognized Indian tribe under section 4(e) of the Indian Self-Determination and Education Assistance Act;

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  a refugee under section 207 of the INA;

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  an asylee under section 208 of the INA;

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  a person whose deportation is withheld under section 243(h) of the INA as in effect prior to April 1, 1997, or whose removal has been withheld under section 241(b)(3) of the INA;

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  a parolee under section 212(d)(5) of the INA for at least one year;

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  a person granted conditional entry under section 203(a)(7) of the INA as in effect prior to April 1, 1980;

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  a Cuban or Haitian entrant as defined in section 501(e) of the Refugee Education Assistance Act of 1980; or

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  a certain alien, or an alien parent of a child, or an alien child of a parent who has:

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    been battered or subjected to extreme cruelty in the U.S. by a spouse, parent, or certain other family members the alien, parent, and/or child lived with; and

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    been determined to need SSI because of this abuse; and

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    a determination from the Department of Homeland Security (DHS) for a certain change in status.

  Persons not in any of the categories listed above who were receiving SSI benefits on August 22, 1996 can continue to receive benefits if they are permanently residing in the United States under color of law.

  Since we do not have proof that you are a U.S. citizen or national, or that you are in one of the alien eligibility categories listed above, or that you are permanently residing in the United States under color of law, you will lose your special SSI eligibility status on                .

  Information About [Medicaid/Medi-Cal/AHCCCS] (Caption will vary.)
  (Language in this section will vary by State. See SI 01730.060 and NL 00804.110)

  You Have Important Appeal Rights

  If you disagree with the decision, you have the right to appeal. We will review your case and consider any new facts you have.

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    You have 60 days to ask for an appeal.

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    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.

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    You must have a good reason for waiting more than 60 days to ask for an appeal.

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    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. The address and phone numbers are shown on the last page of this letter. We can help you fill out the form.

  Appeal in 10 Days To Keep Your SSI Case Active

  You can ask for an appeal any time within 60 days. But if you want us to keep your SSI case active until we decide your case, you must ask for the appeal within the first 10 days.

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    The 10 days start the day after you get this letter.

    However, even if you appeal in 10 days, we may not keep your SSI case active
    beginning           if both of the following are true:

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    The decision we make on your appeal is the same as our earlier decision, and

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    We send or give you a letter with our new decision within the 10 days.

  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.

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    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.

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    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.

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    Formal Conference. This is a meeting like an informal conference. The difference is you can ask us to 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.

  Proofs To Bring If You Contact Us

  If you contact us, the types of documents you can show us include:

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    U.S. birth certificate; or

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    U.S. naturalization papers or U.S. passport; or

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    Proof of your alien status (for example, an DHS Form I-551 or Form I-94 that has not expired); or

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    An order from an immigration judge withholding deportation or removal or granting asylum; or

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    Proof that you are a member of a federally recognized Indian tribe.

  If Your Immigration Status Changes

  If you are not a U.S. citizen or national, you may be able to change your immigration status to one of the eligible alien categories. Contact an DHS district office for information on how you can change your immigration status. You can call DHS toll-free at 1-800-755-0777 to get the location and phone number of the DHS office in your area. You should notify us immediately if DHS changes your immigration status to one of the alien eligibility categories.

  Things To Remember

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    Let us know if you become a U.S. citizen or if your alien status changes and you think you may be eligible.

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    If we stop your special SSI eligibility status and you do not become eligible again before (month/year of 13th month of ineligibility), you may have to file a new application to get SSI.

  If You Have Any Questions

  If you have any questions, you may call us toll-free at 1-800-772-1213, or call your local office at          . We can answer most questions over the phone. You can also write or visit any Social Security office. The office that serves your area is located at:

LOCAL OFFICE STREET ADDRESS
CITY, STATE ZIP

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  If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

  (Signature)
Deputy Commissioner
  for Operations