Supplemental Security Income
Notice of Revised Determination
Date: May 15, 1991
Address Social Security Number: XXX-XX-XXXX
City, State ZIP Code
We are writing to tell you about a change in your Supplemental Security Income (SSI)
payment. The following chart shows the SSI money due you for the month we changed.
As you can see from the chart, we are only changing your payments for one month in
the past. The rest of this letter will tell you more about this change.
Your Payment Is Changed as Follows:
||Amount Due Each Month
|April 01, 1991
||April 30, 1991
Your Payment is Based on These Facts:
If you receive money, gifts, insurance or other payments because of a death, we will
not count what you received against your SSI payments as long as it is spent on expenses
related to the last illness or burial.
You received $2,500.00 in life insurance on Charles Davidson in April 1991.
You spent $2,000.00 on expenses related to his last illness or burial.
We must use the amount you did not spend on his last illness or burial expenses in
figuring your SSI payments. We are using $500 of the money you received in April 1991
to figure your payment for April 1991.
TURN THIS OVER IF YOU THINK WE ARE WRONG
YOUR RIGHT TO APPEAL
Do You Think We're Wrong?
If you think we're wrong, you have the right to appeal. A person who hasn't seen your
case will look at it. That person will be an Administrative Law Judge. In the rest
of our letter we'll call this person an ALJ. The ALJ will correct mistakes and look
at any new facts you have before deciding your case. We call this a hearing.
You have 60 days to ask for a hearing.
The 60 days start the day after you get this letter.
You'll have to have a good reason for waiting more than 60 days to ask for a hearing.
You have to ask for an appeal in writing. We'll ask you to sign an SSA form HA-501,
called “Request for Hearing.” Contact one of our offices if you want help.
How A Hearing Works
A hearing works like this.
The ALJ will tell you the time and place for the hearing.
The ALJ will explain the law in your case. The ALJ will state the known facts and
tell you what has to be decided.
You can tell the ALJ why you think we're wrong. You can give the ALJ more facts. And
you can bring people to say why you're right.
The ALJ can make people come to your hearing and bring important papers. You can question
these people at your hearing.
We'll ask if you want to go to the hearing in person. If you say you want to go, you
should attend if at all possible. If you change your mind or if you can't get to the
hearing, you should tell us. You should know that your being there may help the ALJ
decide your case.
If You Want Help With Your Hearing
You may want help from a friend, lawyer or someone else. There are groups that can
find you a lawyer. Some can give you a free lawyer. We can give you the names of these
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Things to Remember
This decision refers only to your claim for Supplemental Security Income payments.
This determination replaces all previous determinations for the above period.
We may be in touch with you later about any payments we previously made.
If You Have Any Questions
If you have any questions, you may call us at (111) 222-3333. We can answer most questions
over the phone. You may also write or visit any Social Security office. The office
that serves your area is located at:
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