Enter the months that are covered by the retroactive check and the dollar amounts
per month that equals the retroactive check we send to the State.
When amounts for consecutive months are equal, show the beginning date of the first
consecutive month (MM/DD/YY) and the ending date of the last consecutive month (MM/DD/YY)
plus the per month dollar amount ($000).
Enter all prorated dates on separate lines.
Individual was determined eligible for SSI benefits on the application filed on April
13, 2004, and the first month of recurring payments was for September 1, 2004. No
SSI payment was due for April 2004 since it is the E02 month. The individual also
had too much income on July 2004 and, therefore, no SSI payment was due. The State
IAR Agency received an IAR check for $1,500 on August 8, 2004.
5/01/04-06/30/04 - $500 per month
08/01/04-08/31/04 - $500 per month