Social Security Administration
Supplemental Security Income
Notice of Change in Payment
|Social Security Number
CITY/STATE ZIP CODE
|*Type of Payment*
We are writing to tell you about changes in your Supplemental Security Income payments.
The following chart shows the SSI money due you for the months we changed. As you
can see from the chart, we are only changing your payments for months in the past.
The rest of this letter will tell you more about this change.
Your Payments Will Be Changed As Follows:
From Through Amount Due
Information About Your Payments
This action does not change your current payment amount.
See Next Page
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Your Payment Is Based On These Facts
You had monthly income, which must be considered in figuring your eligibility as follows:
Your Social Security benefits— before deductions for Medicare premiums, if any— of
$xxx.xx for November 2000 through December 2000 and $391.00 for January 2001.
Your wages of $xx.xx for November 2000, $xxx.xx for December 2000 and $xxx.xx for
You Can Review The Information in Your Case
The decisions in this letter are based on the law. You have a right to review and
get copies of the information in our records that we used to make the decisions explained
in this letter. You also have a right to review and copy the laws, regulations and
policy statements used in deciding your case. To do so, please contact us. Our telephone
number and address are shown under the heading "If You Have Any Questions."
Things To Remember
We may be in touch with you later about any payments we previously made.
This decision refers only to your claim for Supplemental Security Income payments.
This determination replaces all previous determinations for the above periods.
If You Disagree With The Decision
If you disagree with the decision, 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. 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
You'll have to have a good reason for waiting 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.
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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
If You Have Any Questions
For general information about Supplemental Security Income, visit our website at www.ssa.gov
on the Internet. There, you will also find the law and regulations about Supplemental
Security Income eligibility and SSI payment amounts.
For general questions about SSI or specific questions about your case, you may call
us toll-free at 1-800-772-1213, or call your local Social Security office at 1-508-427-5386.
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If you call or visit our office, please bring this letter with you and ask for (CR).
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.