BASIC (05-11)

NL 00720.330 SSI Supplemental Security Income

SSI062 SSI OFFSET APPLIED AT THE TIME OF INITIAL TITLE II AWARD (B60)

(Requested)

Caption: Your Benefits

We are reducing  (1)  Social Security benefits for  (2)  . This is because we are subtracting the amount of the Supplemental Security Income (SSI) payments which  (3)  received for this period. We subtracted  (4)  because your SSI payments would have been that much less if we had paid the Social Security benefits to  (5)  when they were regularly due.

Fill-in values:

Fill-in (1) System Generated

Choice 1: your

Choice 2: Beneficiary's name possessive

Fill-in (2) Request in date format shown below

Choice 1: MM/CCYY to MM/CCYY

Choice 2: MM/CCYY

Fill-in (3) System Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (4) Requested as a money amount in $$$$$.¢¢

Amount withheld

Fill-in (5) System Generated

Choice 1: you

Choice 2: him

Choice 3: her

SSI066 AWARD CHECK PARAGRAPH SSI OFFSET (B61)

(Requested)

Caption: What We Will Pay

We are paying  (1)  beginning  (2)  .

  •  (3)  will receive  (4)  , which is the money  (5)  due for  (6)  .

  • After that,  (7)  will receive  (8)  each month.

Fill-in values:

Fill-in (1) System Generated

Choice 1: you

Choice 2: Beneficiary's name

Fill-in (2) Requested in date format shown below

MM/CCYY (com + 1)

Fill-in (3) System Generated

Choice 1: You

Choice 2: He

Choice 3: She

Fill-in (4) Request as a money amount in $$$$$.¢¢ format

Amount

Fill-in (5) System Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (6) Requested in date format shown below

MM/CCYY (com)

Fill-in (7) System Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (8)Request as a money amount in $$$$$.¢¢ format

Choice 1: Amount

SSI067 CRITICAL SSI OFFSET CASE (B63)

(Requested)

Caption: What We Will Pay

Although we are sending  (1)   (2)  of the money  (3)  due for the past months, we are withholding your Social Security benefits for  (4)  . We may have to reduce these benefits if  (5)  received Supplemental Security Income (SSI) for this period. When we decide whether or not we have to reduce  (6)  Social Security benefits, we will send  (7)  another letter. We will pay  (8)  any benefits  (9)  due.

Fill-in values:

Fill-in (1) System Generated

Choice 1: you

Choice 2: Beneficiary's name

Fill-in (2) Request as a money amount in $$$$$.¢¢ format

Amount

Fill-in (3) System Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (4) Requested in date format shown below

Choice 1: MM/CCYY to MM/CCYY

Choice 2: MM CCYY

Fill-in (5) System Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (6) System Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (7) System Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (8) System Generated

Choice 1: you

Choice 2: him

Choice 3: her

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