BASIC (11-96)

SI 00832.004 Anderson Notices and Case Report Form

A. Exhibit - form letter to precede automated notice of change of payment - initial review case

NOTE: If the individual is blind or visually impaired, see instructions at NL 01001.010 for more information on the special blind or visually impaired notice options.

SOCIAL SECURITY ADMINISTRATION

SUPPLEMENTAL SECURITY INCOME

IMPORTANT INFORMATION

 

                        Date:

                        Claim Number:

 

Name

Address

City/State/Zip Code

 

We looked at your Supplemental Security Income (SSI) case to see if we owed you money because of the Anderson court case. This case is about how we figure SSI for some people who receive or did receive Veterans benefits that are called Old Law, Section 306, or protected pensions.

Sometimes the Department of Veterans Affairs (VA) pays more money to a person who has a wife, husband, or child than to someone who has no dependent family members. Because we counted as your income the part of your VA benefit you got for a dependent family member, you are  (1)  .

Because you are  (2)  , we are sending you another letter soon telling you:

  • how much SSI you will get and for what months;

  • when to expect your SSI money;

  • the new amount of the Veteran's pension which we used to figure your SSI, and

  • what to do if you disagree with our decision about the amount we owe you.

If You Have Any Questions

If you have any questions, you may call, write, or visit any Social Security office. If you call or visit our office, please have this letter with you and ask for  (2)  . The telephone number is (xxx) xxx-xxxx.

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.

 

                     Manager's Name

                     Title

 

[SSA-L8165-U2]

Fill-ins

1 -Choice 1:due SSI money.
 Choice 2:due more SSI money.
2 -Choice 1:due SSI money
 Choice 2:due more SSI money
   

3 -

Name of contact person

B. Exhibit - manual notice of revised determination

NOTE: If the individual is blind or visually impaired, see instructions at NL 01001.010 for more information on the special blind or visually impaired notice options.

SOCIAL SECURITY ADMINISTRATION

SUPPLEMENTAL SECURITY INCOME

NOTICE OF REVISED DETERMINATION

 

                        Date:

                        Claim Number:

 

Name

Address

City/State/Zip Code

 

We are writing to tell you about changes in your past Supplemental Security Income (SSI) payments. The following chart shows the SSI money due you for the months we changed. The rest of this letter will tell you more about this change.

Your Payments Will Be Changed As Follows:

  Amount
FromThroughDue Each Month
Month/Day/YearMonth/Day/Year$xxx.xx

Information About Your Payments

We are sending you a check for $    . This is money due for MM/YY through MM/YY.

You should receive this check no later than MM/DD/YY.

  (1)  

  (2)  

Your Payment Is Based On These Facts

We looked at your SSI case to see if we owe you money because of the Anderson court case. This case is about how we figure SSI for some people who get Veterans benefits that are called Old Law, Section 306, or protected pensions.

Sometimes the Department of Veterans Affairs (VA) pays more money to a person who has a wife, husband, or child than to someone who has no dependent family members. Because we counted as your income the part of your VA benefit you got for a dependent family member, you are  (3)  because of the Anderson case .

 

[SSA-L8100-U2]

                                     Page 2

 

You have monthly income which must be considered in figuring your payment as follows:

  • Your VA pension of $    for MM/YY through MM/YY.

Things To Remember

This determination replaces all previous determinations for the above periods.

Do You Disagree With The Decision?

If you disagree with our decision, you have the right to ask for a hearing before an Administrative Law Judge (ALJ). The ALJ will review your entire case, even the parts you agree with. The ALJ also will consider any new facts you have and make a new decision. The new decision could be more favorable to you than the one you already have. But, keep in mind that the new decision also could be the same as or less favorable than the decision you already have.

  • You have 60 days to ask for a hearing.

  • 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 if you wait more than 60 days to ask for a hearing.

  • You have to ask for a hearing 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 The Hearing Process Works

The ALJ will mail you a letter at least 20 days before the hearing to tell you its date, time and place. The letter will explain the law in your case and tell you what has to be decided. Since the ALJ will review all facts in your case, it is important that you give us any new facts as soon as you can.

The hearing is your chance to tell the ALJ why you disagree with the decision in your case. You can give the ALJ new evidence and bring people to testify for you. The ALJ also can require people to bring important papers to your hearing and give facts about your case. You can question these people at your hearing.

                                  Page 3

 

It Is Important To Go To The Hearing

It is very important that you go to the hearing. If for any reason you can't go, contact the ALJ as soon as possible before the hearing and explain why. The ALJ will reschedule the hearing if you have a good reason.

If you don't go to the hearing and you don't have a good reason for not going, the ALJ may dismiss your request for a hearing.

If You Want Help With Your Hearing

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 hearing.

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

Please read the enclosed pamphlet “Your Right To An Administrative Law Judge Hearing and Appeals Council Review of Your Social Security Case.” It has more information about the hearing.

If You Have Any Questions

If you have any questions, you may call, write or visit any Social Security office. If you call or visit our office, please have this letter with you and ask for  (5)  . The telephone number is (xxx) xxx-xxxx.

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.

 

                     Manager's Name

                     Title

Enclosure:

Pub 70-10281

                                     Page 4

 

Fill-ins

1 -Choice 1:Also, you are due money for Month/Day/Year through Month /Day/Year. You will receive another letter telling you how much you will get for these months, and when you will get it. If you think we are wrong about the amount we owe you, the letter will tell you what to do. (Use this fill-in when recipient will also receive a systems-generated payment and notice.)
 Choice 2:Null.
2 -Choice 1:This action does not change your current payment.
 Choice 2:Null.
3 -Choice 1:due SSI money
 Choice 2:due more SSI money
   

4 -

Name of contact person

C. Exhibit - manual notice informing individual of ineligibility for anderson relief

NOTE: If the individual is blind or visually impaired, see instructions at NL 01001.010 for more information on the special blind or visually impaired notice options.

SOCIAL SECURITY ADMINISTRATION

SUPPLEMENTAL SECURITY INCOME

IMPORTANT INFORMATION

 

                        Date:

                        Claim Number:

 

Name

Address

City/State/Zip Code

 

You asked us to look at your Supplemental Security Income (SSI) case to see if we owed you money because of the Anderson court case. This case is about how we figure SSI for some people who receive or did receive Veterans benefits that are called Old Law, Section 306 or protected pensions.

Sometimes the Department of Veterans Affairs (VA) pays more money to a person who has a wife, husband, or child than to someone who has no dependent family members. If we counted as your income the part of your VA benefit you got for dependent family members, we may owe you money because of the Anderson case.

However, after looking at the information about your case. we decided that you are
not  (1)  . This is because  (2) 

Do 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. 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 our office. We can help you fill out the form.

How To Appeal

There are two 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 will decide your case again. You will not meet with the person who decides your case.

     

[SSA-L8166-U2]

                                       Page 2

 

  • Informal Conference . You will meet with the person who decides your case. You can tell that person why you think you are right. You can give us more facts to help prove you are right. You can bring other people to help explain your case.

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

If you have any questions, you may call, write, or visit any Social Security office. If you call or visit our office, please have this letter with you and ask for  (3)  . The telephone number is (xxx) xxx-xxxx.

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 vou arrive at the office.

 

 

                     Manager's Name

                     Title

                                   Page 3

 

Fill-ins

1 -Choice 1:due any SSI money.
 Choice 2:due more SSI money.
2 -Choice 1:since November 1981, you did not receive Veterans payments that are called Old Law, Section 306 or protected pensions. These are the only kinds of pensions covered by the Anderson case.
 Choice 2:the VA says your wife/husband was your only dependent, and both of you got SSI payments. We counted the correct amount of VA payments for you and your wife/husband as a couple. As a result, your SSI payments were correct. (This choice does not apply to residents of the Ninth Circuit.)
 Choice 3:your income was too high to get SSI payments even after we counted less of your VA income.
 Choice 4:(give other reason than those in choices 1-3.)
   

3 -

Name of contact person

D. Exhibit - form letter to precede automated notice of change of payment - second review case

NOTE: If the individual is blind or visually impaired, see instructions at NL 01001.010 for more information on the special blind or visually impaired notice options.

SOCIAL SECURITY ADMINISTRATION

SUPPLEMENTAL SECURITY INCOME

IMPORTANT INFORMATION

 

                        Date:

                        Claim Number:

 

Name

Address

City/State/Zip Code

We looked at your Supplemental Security Income (SSI) case again to see if we owed you  (1) because of the Anderson court case. This case is about how we figure SSI for some people who receive or did receive Veterans benefits that are called Old Law, Section 306, or protected pensions.

The court has made a new decision in the Anderson case. Because of this, we have gotten new information from the Department of Veterans Affairs (VA) on the amount of your VA benefit that we count as your income. Therefore, we refigured your SSI payment and find you are  (2)  .

As we told you in another letter about the Anderson court case, sometimes the VA pays more money to a person who has a wife, husband, or child than to someone who has no dependent family members. The amount of your VA benefit we are now counting as income does not include the part of your VA benefit you got for a dependent family member, including your spouse.

Because you are  (3)  , we are sending you another letter soon telling you:

  • how much SSI you will get and for what months;

  • when to expect your SSI money;

  • the new amount of the Veterans pension which we used to figure your SSI, and

  • what to do if you disagree with our decision about the amount we owe you.

     

SSA-L8165

                            Page 2

 

IF YOU HAVE ANY QUESTIONS

If you have any questions, you may call, write, or visit any Social Security office. If you call or visit our office, please have this letter with you and ask for  (4)  . The telephone number is (xxx) xxx-xxxx.

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.

 

                     Manager's Name

                     Title

 

Fill-ins

1 -Choice 1:money
 Choice 2:more money than we already paid you
2 -Choice 1:due SSI money.
 Choice 2:due more SSI money.
3 -Choice 1:due SSI money
 Choice 2:due more SSI money
   

4 -

Name of contact person

E. Exhibit - manual notice of revised determination - second review case

NOTE: If the individual is blind or visually impaired, see instructions at NL 01001.010 for more information on the special blind or visually impaired notice options.

SOCIAL SECURITY ADMINISTRATION

SUPPLEMENTAL SECURITY INCOME

NOTICE OF REVISED DETERMINATION

 

                        Date:

                        Claim Number:

 

Name

Address

City/State/Zip Code

 

We are writing to tell you about changes in your past Supplemental Security Income (SSI) payments. The following chart shows the SSI money due you for the months we changed. The rest of this letter will tell you more about this change.

Your Payments Will Be Changed As Follows:

 

FromThroughAmount Due Each Month
Month/Day/YearMonth/Day/Year$xxx.xx

Information About Your Payments

We are sending you a check for $    . This is money due for MM/YY through MM/YY.

You should receive this check no later than MM/DD/YY.

  (1)  

  (2)  

Your Payment Is Based On These Facts

We looked at your SSI case again to see if we owed you  (3)  because of the Anderson court case. This case is about how we figure SSI for some people who get Veterans benefits that are called Old Law, Section 306, or protected pensions.

The court has made a new decision in the Anderson case. Because of this, we have gotten new information from the Department of Veterans Affairs (VA) on the amount of your VA benefit that we count as your income. Therefore, we refigured your SSI payment and find your are  (4) .

 

SSA-L8100

                            Page 2

 

As we told you in another letter about the Anderson court case, sometimes the Department of Veterans Affairs (VA) pays more money to a person who has a wife, husband, or child than to someone who has no dependent family members. The amount of your VA benefit we are now counting as income still does not include the part of your VA benefit you got for a dependent family member.

You have monthly income which must be considered in figuring your payment as follows:

  • Your VA pension of $    for MM/YY through MM/YY.

Things To Remember

This determination replaces all previous determinations for the above periods.

Do You Disagree With The Decision?

If you disagree with our decision, you have the right to ask for a hearing before an Administrative Law Judge (ALJ). The ALJ will review your entire case, even the parts you agree with. The ALJ also will consider any new facts you have and make a new decision. The new decision could be more favorable to you than the one you already have. But, keep in mind that the new decision also could be the same as or less favorable than the decision you already have.

  • You have 60 days to ask for a hearing.

  • 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 if you wait more than 60 days to ask for a hearing.

  • You have to ask for a hearing 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 The Hearing Process Works

The ALJ will mail you a letter at least 20 days before the hearing to tell you its date, time and place. The letter will explain the law in your case and tell you what has to be decided. Since the ALJ will review all facts in your case, it is important that you give us any new facts as soon as you can.

                            Page 3

 

The hearing is your chance to tell the ALJ why you disagree with the decision in your case. You can give the ALJ new evidence and bring people to testify for you. The ALJ also can require people to bring important papers to your hearing and give facts about your case. You can question these people at your hearing.

It Is Important To Go To The Hearing

It is very important that you go to the hearing. If for any reason you can't go, contact the ALJ as soon as possible before the hearing and explain why. The ALJ will reschedule the hearing if you have a good reason.

If you don't go to the hearing and you don't have a good reason for not going, the ALJ may dismiss your request for a hearing.

If You Want Help With Your Hearing

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 hearing.

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

Please read the enclosed pamphlet “Your Right To An Administrative Law Judge Hearing and Appeals Council Review of Your Social Security Case.' It has more information about the hearing.

If You Have Any Questions

If you have any questions, you may call, write or visit any Social Security office. If you call or visit our office, please have this letter with you and ask for  (5)  . The telephone number is (xxx) xxx-xxxx.

 

                            Page 4

 

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.

 

                     Manager's Name

                     Title

 

Enclosure:

Pub 70-10281

 

Fill-ins

1 -Choice 1:Also, you are due money for Month/Day/Year through Month /Day/Year. You will receive another letter telling you how much you will get for these months, and when you will get it. If you disagree with our decision about the amount we owe you, the letter will tell you what to do. (Use this fill-in when recipient will also receive a systems-generated payment and notice.)
 Choice 2:Null.
2 -Choice 1:This action does not change your current payment.
 Choice 2:Null.
3 -Choice 1:SSI money
 Choice 2:more SSI money than we already paid you
4 -Choice 1:due SSI money
 Choice 2:due more SSI money than we already paid you
   

5 -

Name of contact person

F. Exhibit - manual notice informing individual of ineligibility for anderson relief - second review case

NOTE: If the individual is blind or visually impaired, see instructions at NL 01001.010 for more information on the special blind or visually impaired notice options.

SOCIAL SECURITY ADMINISTRATION

SUPPLEMENTAL SECURITY INCOME

IMPORTANT INFORMATION

 

                        Date:

                        Claim Number:

 

Name

Address

City/State/Zip Code

 

We looked at your Supplemental Security Income (SSI) case again to see if we owed you money because of the Anderson court case. This case is about how we figure SSI for some people who receive or did receive Veterans benefits that are called Old Law Section 306 or protected pensions.

The court has made a new decision in the Anderson case.- Because of this, we have gotten new information from the Department of Veterans Affairs (VA) on the amount of your VA benefit that we count as your income. Therefore, we refigured your SSI payment. However, after looking at the information about your case, we decided that you are not .

This is because  (2)  .

As we told you in another letter about the Anderson court case, sometimes the VA pays more money to a person who has a wife, husband, or child than to someone who has no dependent family members. The amount of your VA benefit we are now counting as income does not include the part of your VA benefit you got for a dependent family member, including your spouse.

DO 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. 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 our office. We can help you fill out the form.

 

SSA-L8166

                            Page 2

 

HOW TO APPEAL

There are two 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 will decide your case again. You will not meet with the person who decides your case.

  • Informal Conference . You will meet with the person who decides your case. You can tell that person why you think you are right. You can give us more facts to help prove you are right. You can bring other people to help explain your case.

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 col lect it.

IF YOU HAVE ANY QUESTIONS

If you have any questions, you may call, write, or visit any Social Security office. If you call or visit our office, please have this letter with you and ask for  (3)  . The telephone number is (xxx) xxx-xxxx.

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.

 

 

                     Manager's Name

                     Title

                            Page 3

 

Fill-ins

1 -Choice 1:due any SSI money.
 Choice 2:due more SSI money.
 Choice 3:due more SSI money than we already paid you
 Choice 4:due any more SSI money for Month/Day/Year through Month/Day /Year. (Use this choice with fill-in 2, choice 1.)
2 -Choice 1:the new amount of your VA benefit is more than the VA benefit amount we already counted. Also, you are due less SSI beginning Month/Day/ Year. You will receive another letter telling you what your new SSI payment will be, and when you will get it. If you disagree with our decision about the amount you will get, the letter will tell you what to do. (Use this fill-in when the recipient will also receive a systems-generated payment and Notice of Planned Action.)
 Choice 2:your income was too high to get SSI payments even after we counted the new amount of VA payments.
 Choice 3:(give other reason than those in choice 1 or 2.)
   

3 -

Name of contact person

G. Exhibit — anderson case report

(Revised 8/92)

Destroy all prior additions

 

ANDERSON CASE REPORT

                                   A1

 

Prepare this report for each Anderson case review, regardless of the outcome. Send these reports to your ARC, Programs, at the end of the month. PLEASE PRINT.

 

               DATE REPORT PREPARED:       MM/DD/YY

IDENTIFYING DATA

SSN:    -  -    

HUN:    -  -    

Claimant/Recipient Name:    First     M.I.   Last     

  • Mailing Address:      

    City/State/Zip Code:      

     

OUTCOME OF CASE REVIEW (check one)

(J)Class Member Due UP
(F)Class Member NOT Due UP
 

Reason: (Check the reason that appears HIGHEST on the list)

 (02) Excess income
 (03) Excess resources
 (05) Other - Reason:          
(F)(06) Nonclass Member - Reason:          

 

FO CONTACT INFORMATION

FO Code:     FO Contact:      

         Phone No. : (     )    -    

H. Exhibit — anderson report of contact

 

G-SI_00832.004H

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To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0500832004
SI 00832.004 - Anderson Notices and Case Report Form - 09/16/2014
Batch run: 09/16/2014
Rev:09/16/2014