This exhibit illustrates the T16 (NSSBP) Prison initial determination notice with
possible fill-in choices in the DPS.
Social Security Administration
Supplemental Security Income
[Date of mailing]
Claim Number: SSN
Payee name and address
Our records show (_*F1_) due a Supplemental Security Income (SSI) back payment of
However, we cannot pay the back payment while (_*F3_) confined throughout the month
in a public institution that is a jail, prison, or other correctional facility.
Please contact us when (_*F4_) released. We may be able to pay the back payment then.
You Can Review The Information In (_*F5_) Case
The decisions in this letter are based on the law and information in our records.
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 (_*F6_) case.
To do so, please contact us. Our telephone number and address are shown under the
heading "If You Have Questions."
If You Disagree With The Decision
If you disagree with the decision, you have the right to appeal. We will review your
case and look at 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
You must have a good reason if you wait more than 60 days to ask for an appeal.
To appeal, you must fill out a form called "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 way you want. If you meet with us in
person, it may help us decide your case.
Case Review - You have the 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.
Informal Conference - You'll meet with the person who decides your case. You can tell
that person why you think you're right. You have the right to review the facts in
your file. You can give us more facts to help prove you are right. You can bring other
people to help explain your case.
If You Want Help With Your Appeal
You can have a friend, representative, or someone else help you. There are groups
that can help you find a representative or give you free legal services if you qualify.
There also are representatives 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 Questions
For general information about SSI, visit our website at http://www.socialsecurity.gov/ on the Internet. You will find the law and regulations about SSI eligibility and
SSI payment amounts at http://www.socialsecurity.gov/SSIrules/.
For general questions about SSI or specific questions about (_*F7_) case, you may
call us toll-free at 1-800-772-1213 or call your local Social Security office at (_*F8_). If you call or visit our office,
please bring this letter with you and ask for (_*F9_).
Social Security Administration
*F1 – you are
*F1 – recipient name is
*F2 – amount of back payment
*F3 – you are
*F3 – he is
*F3 – she is
*F3 - recipient name is
*F4 – you are
*F4 – he is
*F4 – she is
*F4 – recipient name is
*F5 – Your
*F5 – His
*F5 – Her
*F5 – recipient name (possessive)
*F6 – your
*F6 – his
*F6 – her
*F6 – recipient name (possessive)
*F7 – your
*F7 – recipient name (possessive)
*F8 – User phone number
*F9 – User name