In underpayments and reduced overpayments, use the following paragraphs to explain
the reasons for the change.
“You had monthly income which must be considered in figuring your payment as follows:
Your social security benefits (before deductions for Medicare medical insurance premiums)
of $$$.00 for MM/YY, $$$.00 for MM/YY and/or $$$.00 for MM/YY through MM/YY.
In figuring your SSI before, we used $$$.00 for MM/YY, $$$.00 for MM/YY and $$$.00
for MM/YY, as your monthly social security income. These were the amounts before deductions
for Medicare premiums, if any. However, fees of $$$.00 were approved to pay the representative
in your social security claim. We subtract these fees from the social security income
If the SSI recipient has a representative payee, substitute for “you ” and “your” in the paragraph, the recipient's name, “he” or “she,” or “his” or “her,” as appropriate.
In the second paragraph, enter the amounts and the month(s) and year(s) that apply
after subtraction of the fee. In the third paragraph, enter the prior amounts of Title
II income and the months and years they apply. In the third paragraph, enter the amount
of the authorized fees.