TN 13 (11-10)

SI 02003.040 Manual Preparation of the SSA-8125 and SSA-L8125-F6, Notice to the State for Exception Cases and Proration Cases

Use the instructions to process the eIAR exception cases described in SI 02003.023.

A. Procedure for completing section of SSA-8125

NOTE: The SSA-8125 is obsolete due to the implementation of eIAR. This reference is retained in POMS because the form may be encountered in pipeline cases.

1. PART I State Agency Identifying Information

Complete the following sections of the SSA-8125.

Item

Action

TO:

Enter the name and address of the State agency receiving the IAR check.

DATE:

Enter the date the notice is prepared.

GR CODE:

Enter the State and county code of the State Agency receiving the IAR check - the same code posted to the SSR.

2. PART II Claimant Information

Item

Action

NAME AND ADDRESS:

Enter the recipient's name and mailing address. If the recipient has a representative payee, enter the payee's name and address, as well as the recipient's name.

CLAIM

Enter one of the following:

  • Initial Claim - if no payment has been made.

  • Posteligibility - if any payment had been made, benefits were suspended or terminated but subsequently reinstated, including the recurring payment.

SOCIAL SECURITY NUMBER:

Enter the recipient's Social Security number.

DATE OF SSI ELIGIBILITY:

  • Enter the date (MM/DD/YY) of the individual's SSI eligibility in both initial claims and posteligibility.

  • Enter Deceased (MM/DD/YY) if recipient dies before payment is made.

  • Leave blank if initial claim is denied.

AMOUNT OF SSI RETROACTIVE PAYMENT:

  • Enter the amount of the retroactive IAR payment being sent to the State agency if there is an underpayment.

  • Enter zero if there is no retroactive payment due.

AMOUNT AND MONTH OF RECURRING SSI PAYMENT:

  • Enter the amount of the first recurring SSI payment and the month the recipient received the payment.

  • Enter zero if there is no recurring payment due.

3. PART III Payment Summary

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.

EXAMPLE:

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.

Enter:

5/01/04-06/30/04 - $500 per month

08/01/04-08/31/04 - $500 per month

B. Procedure for completing the SSA-L8125-F6 for eIAR exception cases, dedicated account, and installment payment, or attorney fee, or eligible non-attorney fee payment involved

Complete the following pages of the SSA-L8125-F6 for an IAR Payment Pending related case:

  • Page 1 - State Agency Identifying Information

  • Page 3 – Claimant Information

  • Page 4 – Retroactive Amount Due Summary

  • Page 5 - Same as Page 4-If Necessary

  • Page 6 - Same as Page 4-If Necessary

1. Page 1 State Agency Identifying Information

Item

Action

TO:

Enter the name and address of the State agency receiving the IAR check.

DATE:

Enter the date the notice is prepared.

CLAIM NUMBER:

Enter the social security number (SSN).

GR CODE:

Enter the State and county code of the State agency receiving the IAR check - the same date posted to the SSR.

IAR PAYMENT PENDING CASE:

Enter the complete address of the servicing FO.

2. Page 3 Claimant Information

Item

Action

Initial Claim

Check if applicable.

Post-Eligibility Claim

Check if applicable.

Other

Check only if future instructions require it.

Recipient's Name

Enter the recipient's name.

SSN

Enter the recipient's SSN.

Representative Payee Name

Enter the payee's name if applicable.

Date of SSI Eligibility

Enter the date (MM/DD/YY) of SSI eligibility in both IC or PE claims.

NOTE: Also enter deceased (MM/DD/YY) if the recipient dies before payment is made. Leave blank if IC/PE denied.

Amount of SSI Retroactive Benefits Due

Enter the amount of SSI retroactive benefits due being sent to the State. If no underpayment due enter "0".

Amount and Month of Recurring SSI Payment

Enter the amount and month of recurring SSI payment. Enter "0" if no recurring payment due.

Under the block labeled (TO: Social Security Administration Address) Record the servicing FO address.

a. State's Account of Reimbursement Claimed

Item

Action

Date Returned to SSA

Enter date servicing FO received SSA-L8125-F6 from the State.

GR Code

Enter the GR Code.

NOTE: State completes all other items in this section.

b. To Be Completed by SSA

Item

Action

SSA Telephone #

Enter the SSAFO telephone number.

Amount of reimbursement check(s) released to the State

Enter amounts.

Date

Enter the date the last IAR check was released to the State.

BY

Enter the name of the FO worker completing the SSA-L8125-F6. Enter no check due if claim denied or no IAR due.

3. Pages 4, 5, and 6 of the retroactive amount due summary

Enter the months covered by the retroactive check and the dollar amounts per month equal to the retroactive check. When the amount 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 any prorated dates for a PE case on a separate line.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0502003040
SI 02003.040 - Manual Preparation of the SSA-8125 and SSA-L8125-F6, Notice to the State for Exception Cases and Proration Cases - 11/19/2010
Batch run: 11/24/2010
Rev:11/19/2010