TN 1 (03-93)

SI 02101.008 SSI Notices to Survivors

A. Procedure

FO, follow the procedure below for notice preparation:

  • Use Form SSA-L8166-U2, Important Information, to notify any survivor or individual about payment or denial of an SSI underpayment due on a deceased individual's record.

  • Use the examples shown below to assist in developing and writing the proper language for each manual notice released.

  • Complete section “Your Payment is Based on These Facts,” correctly and accurately, including all facts essential for the individual to understand the reasons for denial or the amount of the check being released.

    Include such facts as:

    • LISH not met;

    • Individual no longer a child;

    • Individual did not show proof of marriage to deceased; or

    • State was reimbursed because of IAR authorization

NOTE: The most relevant facts should always be listed so the individual will fully understand the reason why they have or have not received an underpayment.

B. Exhibit

Situation 1 — Notice to Pay Survivors

1. Fill-Ins

 

 

We are paying surviving parent(s), spouse, or both. Use on an SSA-L8166-U2, Important Information.

 

We are writing to tell you that we can pay yo Supplemental Security Income (SSI) that was due your   (1)   ,   (2)   , for   (3)    .   (4)  

Information About Your Payment

  (5)   and   (6)   for the months listed below. We show the amount(s)   (7)   should have received in the table below. Since we   (8a or b)   , for the month(s) listed below, you are due $   (9)   .

MonthAmount Due for Each Month
  (10)  $   (11)  
Total Amount Due$   (12)  
Amount Already Paid$   (13)  
Balance Due You$   (14)  
You should receive the payment$   (15)   about   (16)   .

 

Fill-ins:

(1)Choice 1 - child
Choice 2 - spouse
(2)Name of deceased
(3)Choice 1 - Month/Year
Choice 2 - Month/Day/Year through Month /Day/Year
(4)NOTE: For the following fill-in:
 
  • Use choice 1 if a portion of the payment will go to parent(s) and a spouse.

  • Use Choice 2 (Null), if ALL of the payment is going to either parent(s) or a spouse.

    Choice 1 - Under our rules, this is the time.   (a or b)   was considered   (c or d)   .

    (a) she

    (b) he

    (c) your child

    (d) an adult

    Choice 2 - Null

(5)Name of deceased
(6)Choice 1 - not paid
Choice 2 - paid incorrectly
(7)Choice 1 - she
Choice 2 - he
(8)Choice 1 - already paid   (a or b)  
 (a) her $      
 (b) him $      
(9)Balance due
(10)Month/Year
(11)Amount due each month*
(12)Total Amount Due
(13)Amount Already Paid (Same as 8, Choice 1)
(14)Balance Due You (Same as 9)
(15)Balance due (Same as 14)
(16)Month/Day/Year (2 weeks from date on notice)

2. Example of Situation 1

 

  
 Social Security Administration
Supplemental Security Income
Important Information

 

 
 
 Office Address
Office Hours
Telephone Number (XXX)XXX-XXXX
Social Security Number:XXX-XX-XXXX
Date: July 5, 1993
  
 Name
Street Address
City, State ZIP
 We are writing to tell you that we can pay you Supplemental Security Income (SSI) that was due your child, Bob Davie, for March 1, 1993 through May 31, 1993. 
 Under our rules, this is the time he was considered your child. 
 Information About Your Payment 
 Bob Davie was paid incorrectly for the month(s) Ilisted below. We show the amount(s) Ihe should have received in the table below. Since we already paid him $1,11172 for the month(s) listed below, you are due $130. 

 

MonthAmount Due for Each Month
March 1993$ 434.00
April 1993434.00
May 1993   434.00
Total Amount Due$1,302.00
Amount Already Paid   $1,172.00
Balance Due You$ 130.00
 You should receive the payment of $130.00 about July 19, 1993. 
 Your Payment Is Based On These Facts T• Bob Davie was living in your household for March 1, 1993 through May 31, 1993. T• Bob Davis was not considered to be a child after May 1993. T• Parents can only be paid for the period when an individual was a child. 
 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. 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 for waiting more than 60 days to ask for an appeal. 
 • To appeal, you must fill out a form call "Request for Reconsideration." The form number is SSA-561. To get this form, contact one of our offices. We can help you will 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'll decide your case again. You won't meet with the person who decides your case. This is the only kind of appeal you can have to appeal you can have to appeal a medical decision. 
 • Informal Conference. You'll meet with the person who decides your case. You can tell that person why you think you're right. You can give us more facts to help prove you're 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 find a lawyer or give you free legal services if you qualify. There are also lawyers who do not change 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. 
 XXXXXXX-XX-XXXX 
 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                   . The telephone number is shown on page 1 of this letter. 
 Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly. 

 

                          Manager 

C. Exhibit

Situation 2 — Notice For Reimbursement to State and Survivor

1. Fill-Ins

 

The deceased signed an interim assistance reimbursement (IAR) agreement with a State agency. The deceased's first SSI payment was sen to the State Agency. A portion of the payment is not due the State Agency and was return to SSA and is passed on the survivor(s). Use on an SSAL-L8166-U2, Important Information.

We are writing to tell you that we can pay you part of the Supplemental Security Income (SSI) that was due your   (1)   ,   (2)   , for   (3)   . You are not due all the SSI for the   (4)   . This is because   (5)   agreed in writing to   (6)   first SSI payment sent to   (7)   . That agency paid    (8)   while   (9)   was waiting for SSI. The agency kept $   (10)   of the first SSI payment, because that is the amount it paid   (11)   . We are sending you $   (12)   , the amount left from the SSI payment.

Information About Your Payment

MonthSSI AmountAmount State Paid
  (13)  $   (14)  $   (15)  
 $   (16)  $   (17)  
  Your payment: $   (18)  

 

You should receive the payment $   (19)   about   (20)   .

XXX-XX-XXXX

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. 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 for waiting more than 60 days to ask for an appeal.

  • To appeal, you must fill out a form call "Request for Reconsideration." The form number is SSA-561. To get this form, contact one of our offices. 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'll decide your case again. You won't meet with the person who decides your case. This is the only kind of appeal you can have to appeal a medical decision.

  • Informal Conference. You'll meet with the person who decides your case. This is the only kind of appeal you can have to appeal you can have to appeal a medical decision.

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                . The telephone number is shown on page 1 of this letter.

Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly.

                              Manager

Fill-ins:

(1)Choice 1 - child

Choice 2 - spouse
(2)Name of deceased
(3)Choice 1 - Month/Year
Choice 2 - Month/Day/Year through Month /Day/Year
(4)Choice 1 - month
Choice 2 - period
(5)Choice 1 - you
Choice 2 - your spouse
(6)Choice 1 - her
Choice 2 - his
(7)Name of State Assistance Agency
(8)Choice 1 - her
Choice 2 - him
(9)Choice 1 - she
Choice 2 - he
(10)Amount retained by State Assistance agency
(11)Choice 1 - her
Choice 2 - him
(12)Total payment due
(13)Month/Year*
(14)Amount of SSI for month*
(15)Amount of State payment for month*
(16)Total SSI amount
(17)Total paid by State agency
(18)Total payment due (Same as 12)
(19)Total payment due (Same as 12)
(20)Total Month/Day/Year (2 weeks from date on notice)

 

2. Example of Situation 2

Situation 2 — Notice For Reimbursement to State and Survivor (Cont.)

 Social Security Administration
Supplemental Security Income
Important Information

 

 
 
 Office Address
Office Hours
Telephone (XXX)XXX-XXXX
Social Security Number: XXX-XX-XXXX
Date: August 5, 1993
  
 Name
Street Address
City, State, ZIP
 We are writing to tell you that we can pay you part of the Supplemental Security Income (SSI) that was due your child, Sarah Browne, for April 1, 1993, through June 30, 1993. You are not due all the SSI for that period. This is be because you agreed in writing to have her first SSI payment sent to the County Department of Social Services. That agency paid her while she was waiting for SSI. The agency kept $450 of the first SSI payment, because that is the amount it paid had. We are sending you $852, the amount left from the SSI payment. 
 Information About Your Payment
MonthSSI AmountAmount State Paid
April 1993$ 434.00$ 150.00
May 1993434.00150.00
June 1993   434.00     150.00  
 $1,302.00$ 450.00
  Your Payment: $842.00
 You should receive the payment of $852.00 about August 19, 1993. 
 Your Payment Is Based On These Facts 
 • Sarah Browne filed an application for SSI on April 1, 1993 
 • She lived in the State of North Carolina from April 1993 through June 1993. 
 • She was living in your household for April 1993 through June 1993. 

D. Exhibit

Situation 3 — Notice For Reimbursement to IAR State

1. Fill-Ins

 

 

The deceased signed an IAR agreement with a State agency. The total payment is due the State Agency. Use on an SSI-L8186-U2, Important Information.

We are writing to tell you that we cannot pay you any Supplemental Security Income (SSI) that was due your   (1)   ,   (2)   , for   (3)   . This is because   (4)   agreed in writing to have   (5)   first SSI payment sent to   (6)   . That agency paid   (7)   while   (8)   was waiting for SSI.

Fill-ins:

(1)Choice 1 - child
Choice 2 - spouse
(2)Name of deceased
(3)Choice 1 - Month/Year
Choice 2 - Month/Year through Month/Year
(4)Choice 1 - you
Choice 2 - your spouse
(5)Choice 1 - her
Choice 2 - his
(6)Name of State Assistance Agency
(7)Choice 1 - her
Choice 2 - him
(8)Choice 1 - she
Choice 2 - he

 

2. Example of Situation 3

Situation 3 — Notice For Reimbursement to IAR State (Cont.)

 Social Security Administration
Supplemental Security Income
Important Information

 

 
 
 Office Address
Office Hours
Telephone Number: (XXX) XXX-XXXX
Social Security Number: XXX-XX-XXXX

 

 Name
Street Address
City, State ZIP
 We are writing to tell you that we cannot pay you any Supplemental Security Income (SSI) that was due your child, Kenny Block, for April 1, 1993 through July 31, 1993. This is because you agree in writing to have his first SSI payment sent to the County Department of Social Services. That agency paid him while he was waiting for SSI. 
 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. We assume you got this letter 5 days after the date on it unless you show us that you did not get it within 5 day period. 
 • You must have a good reason for writing more than 60 days to ask for an appeal. 
 • To appeal, you must fill out a form call "Request for Reconsideration." The form number is SSA-561. To get this form, contact one of our offices. We can help you fill out the form. 
 XXX-XX-XXXX 
 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'll decide your case again. You won't meet with the person who decides your case. This is the only kind of appeal you can have to appeal a medical decision. 
 • Informal Conference. You'll meet with the person who decides your case. You can tell that person why you think you're right. You can give us more facts to help prove you're 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                     . The telephone number is shown on page 1 of this letter. 
 Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly. 
                                 Manager 

E. Exhibit

Situation 4 — Notice to Use Underpayment to Reduce Overpayment of Survivor

1. Fill-Ins

 

We are writing to tell you that we can pay you the Supplemental Security Income (SSI) that was due your   (1)   ,   (2)   , for   (3)   .   (4)   was   (5)   for this    (6)   . We show the amount   (7)   should have received in the table below.   (8)  

As we told you before in another letter, you have an overpayment of $    (9)   on your own record. We will use the $   (10)   due you on   (11)   record to   (12)   your overpayment. As a result, your overpayment will be   (13)  

Information About Your Payment

MonthAmount Due for Each Month
  (14)   $   (15)   
Total SSI Due on   (16)   Record   (17)  
Amount Applied to Your Overpayment$   (18)  
You are due..........$   (19)  

Fill-ins:

(1)Choice 1 - child
Choice 2 - spouse
(2)Name of deceased
(3)Choice 1 - Month/Year
Choice 2 - Month/Date/Year through Month /Day/Year
(4)Choice 1 - She
Choice 2 - He
(5)Choice 1 - not paid
Choice 2 - paid incorrectly
(6)Choice 1 - month
Choice 2 - period
(7)Choice 1 - she
Choice 2 - he
(8)Choice 1 - Since we already paid   (a or b)   $   (c)   , you are due $   (d)  
 (a) her
 (b) him
 (c) amount of SSI previously paid to deceased
 (d) amount due survivor
 Choice 2 - Null
(9)Amount of survivor's overpayment
(10)Amount of SSI underpayment
(11)Name of deceased (possessive)
(12)Choice 1 - reduce
Choice 2 - pay off
(13)Choice 1 - reduce to $   (a)   .
 (a) amount of reduced overpayment
 Choice 2 - paid in full
 Choice 3 - paid in full. We will send you the remaining $   (a)   . You should receive the payment about   (b)   .
 (a) balance due to survivor
 (b) Month/Day/Year (2 weeks from date on notice)
(14)Month/Year*
(15)Amount due for month*
(16)Name of deceased (possessive)
(17)Amount of SSI underpayment (Same as 10)
(18)Amount applied to survivor's overpayment
(19)Balance due to survivor

NOTE: If entire underpayment is used to pay off or reduce overpayment, the balance due will be $0.

2. Example of Situation 4

Situation 4 — Notice to Use Underpayment to Reduce Overpayment of Survivor (Cont.)

 Social Security Administration
Supplemental Security Income
Important Information

 

 
 
 Office Address
Office Hours
Telephone Number: (XXX) XXX-XXXX
Social Security Number: XXX-XX-XXXX
Date: October 5, 1993

 

 Name 
Street Address
City, State, ZIP

 

 We are writing to tell you that we can pay you the Supplemental Security Income (SSI) that was due your child, Sally Long, for August 1993. She was not paid for this month. We show the amount she should have received in the table below. 
 As we told you before in another letter, you have an overpayment of $205 on your own record. We will use the $434 due you on Sally Long's record to pay off your overpayment. As a result, your overpayment will be paid in full. We will send you the remaining $229. You should receive the payment about October 19, 1993. 
 Information About Your Payment
MonthAmount Due for Each Month
August 1993$434.00
Total SSI Due on Sally Long's Record$434.00
Amount Applied to Your Overpayment   205.00 
You are due............$229.00
 XXX-XX-XXXX 
 Your Payment Is Based On These Facts 
 • Sally Long filed an application for SSI March 1, 1993. 
 • Sally Long was living in your household for March 1, 1993, through September 18, 1993. 
 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 a appeal. 
 • 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 for waiting more than 60 days to ask for an appeal. 
 • To appeal, you must fill out a form call "Request for Reconsideration." The form number is SSA-561. To get this form, contact one of our offices. 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'll decide your case again. You won't meet with the person who decides your case. This is the only kind of appeal you can have to appeal a medical decision. 
 • Informal Conference. You'll meet with the person who decides your case. You can tell that person why you think you're right. You can give us more facts to help prove you're right. You can bring other people to help explain your case. 
 XXX-XX-XXXX 
 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. You 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                 . The telephone number is shown on page 1 of this letter. 
 Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly. 
                            Manager 

F. Exhibit

Situation 5 — Notice to Deny Underpayment

1. Fill-Ins

 

Denial of request. Use on an SSA-L8166-U2, Important Information

We are writing about your request for Supplemental Security Income (SSI) on the account of   (1)     (2)   . We cannot pay you because   (3)   .

Fill-ins:

(1)Choice 1 - your spouse
Choice 2 - your child,
Choice 3 - Null
(2)Name of deceased
(3)Reason for denial (Use dictated language.)

2. Example of Situation 5

Situation 5 — Notice to Deny Underpayment (Cont.)

 Social Security Administration
Supplemental Security Income
Important Information

 

 
 
 Office Address
Office Hours
Telephone Number: (XXX) XXX-XXXX
Social Security Number: XXX-XX-XXXX
Date: November 5, 1993

 

 Name 
Street Address
City, State, ZIP

 

 We are writing to you about your request for Supplemental Security Income (SSI) on the account of Marvin Black. We cannot pay you because you did not give us proof that you were married to Marvin Black. 
 Do You Disagree With The Decision? 
 If you disagree with our 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. 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 for waiting more than 60 days to ask for an appeal. 
 • To appeal, you must fill out a form call "Request for Reconsideration." The form number is SSA-561., To get this form, contact one of our offices. We can help you fill out the form. 
 XXX-XX-XXXX 
 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 facts to add to your file. Then we'll decide your case again. You won't meet with the person who decides your case. This is the only kind of appeal you can have of appeal you can have to appeal a medical decision. 
 • Informal Conference. You'll meet with the person who decides your case. You can tell that person why you think you're 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                  . The telephone number is shown on page 1 of this letter. 
 Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly. 
                             Manager

G. Exhibit

Situation 6 — Notice For Denial to an Estate

1. Fill-Ins

 

Denial of request for payment to estate. Use on an SSA-L8166-U2,

Important Information

We are writing about your request for Supplemental Security Income (SSI) that was due   (1)   . You told us that you represent   (2)   estate. The law does not allow us to make payments to a deceased person's estate. Therefore, we cannot pay the estate.

Fill-ins:

(1)Name of deceased
(2)Choice 1 - her
Choice 2 - his

2. Example of Situation 6

Situation 6 — Notice For Denial to an Estate (Cont.)

 Social Security Administration
Supplemental Security Income
Important Information

 

 
 
 Office Address
Office Hours
Telephone Number: (XXX) XXX-XXXX
Social Security Number: XXX-XX-XXXX
Date: November 5, 1993

 

 Name 
Street Address
City, State, ZIP

 

 We are writing about your request for Supplemental Security Income (SSI) that was due Alvin North. You told us that you represent his estate. The law does not allow us to make payments to a deceased person's estate. Therefore, we cannot pay the estate. 
 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. We assume you got this letter 5 days after the date on it unless you show us that you did not get within the 5 day period. 
 • You must have