TN 3 (02-97)

NL 00802.025 Completion of the Manual SSA-L8030-U2, Notice of Disapproved Claim

A. Introduction

The SSA-L8030-U2 is a manual form with preprinted appeal rights. Select captions and paragraphs from those shown below to produce a complete notice. The SSA-L8030 is also on the DOCS for completing notices on the personal computer. It directs the user to select appropriate paragraphs and fill-ins to complete the notice.

B. Procedure

NL 00802.001B through NL 00802.001C explain how to use the charts below for completing notices and the procedure for preparing a manual notice.

1. Chart for Completion of the SSA-L8030-U2

The following chart provides a list of the captions and paragraphs you must consider when preparing the body of the SSA-L8030-U2.

  1. WHY WE CAN'T PAY YOU (Caption 1903) (Mandatory)

NL ReferenceParagraphUse
NL 00804.2151500
N12 — Use both paragraphs if the claimant has withdrawn the application.
  The paragraphs for nonmedical denials follow:
NL 00804.1751239N01 — Excess income.
NL 00804.1801293N04—The claimant has excess resources. (Use with 1294—see b. below.)
NL 00804.1651200N02 — Resident of a public institution. (Use this paragraph if INTM50 and INTM51 below do not apply.)
NL 00804.1702220N13 — Not a U.S. citizen or eligible alien.
 1216N03—Not residing in U.S.
NL 00804.1401116
N14 — Claimant has not attained age 65. Choose appropriate paragraph.
NL 00804.1351110N18 — Did not produce requested information.
 1105N17—Failure to pursue claim.
NL 00804.1301081N06 — Failure to file for other benefits.
NL 00804.1151392An individual can qualify for SSI on the basis of disability or blindness.
NL 00804.2001407Claimant disabled but ineligible for SSI for other reasons.
Claimant performing substantial gainful activity (SGA). Choose appropriate paragraph.
  1. HOW YOU MAY BE ABLE TO RECEIVE SSI (Caption 1929) (Use only when you use paragraph 1293 above.)

NL ReferenceParagraphUse
NL 00804.1801294Provides information about a conditional payment agreement.
  1. OUR DECISION IS BASED ON THESE FACTS (Caption 1906) (Mandatory caption for excess income, N01 denials.)

NL ReferenceParagraphUse
NL 00804.1451130Individual is eligible in more than one category or, if a child, age is given.
 1131Claimant filing as member of a couple. Spouse is eligible.
NL 00804.1501145Individual was both a student and non-student for the period of time covered on the record.
NL 00804.1601161Spouse is eligible for part of initial period of eligibility.
 1183Couple not living together.
NL 00804.1551165Use if the claimant is a child living in the household of the parent(s) or the federal living arrangement code is “D”.
NL 00804.1901315Tells claimant's county and/or State of residence. (Mandatory)
 1163Tells claimant's State living arrangement. (Mandatory for States that pay an optional State supplement.)
 1169State involvement.
 1168State living arrangement.
NL 00804.1701001
Use both paragraphs if sponsor-to-alien deeming applies.
NL 00804.1751231
Lead-in paragraphs to introduce income. Choose appropriate paragraph.
Windfall offset applies — Choose the appropriate paragraph.
 1232Describes type, period and amount of income.
 1248Income of spouse or parent(s) deemed to claimant.
 1258The value of the one-third reduction (VTR) applies.
 1260Claimant receives in-kind support and maintenance.
 1253Claimant received a one-time payment of unearned income.
 1254Spouse or parent(s) received a one- time payment of unearned income.
Choose any applicable paragraphs to address what is not income or what is disregarded from income.
  1. ABOUT YOUR OVERPAYMENT (Caption 1909) (Use only if the claimant received an overpayment because of incorrect payments we made while we were still working on the claim.)

NL ReferenceParagraphUse
NL 00804.2051042Claimant received PD/PB payments and is ineligible because not disabled and overpaid for reasons other than disability/blindness.
NL 00804.2101437Request for refund of overpayment.
 1439Claimant received SSI payments while we worked on claim and is ineligible.
  1. IF YOU THINK YOU SHOULDN'T HAVE TO PAY US BACK (Caption 1911) (Use only if you have used the preceding caption.)

NL ReferenceParagraphUse
NL 00804.2101434(Mandatory paragraph for this caption.) Provides claimant with waiver information.
  1. INFORMATION ABOUT MEDICAID AND OTHER BENEFITS (Caption 1915) (Mandatory) (Use “AND OTHER BENEFITS” as part of the caption when paragraph 1311 below is used.)

NL ReferenceParagraphUse
NL 00804.1901311State administers its own supplementation program.
NL 00804.1101150
Choose the appropriate Medicaid referral paragraph for the claimant's State of residence.
  1. THINGS TO REMEMBER (Caption 1926) (Mandatory)

NL ReferenceParagraphUse
NL 00804.2401481Advises the claimant to refile if he/she believes he/she can qualify for SSI. (Mandatoryparagraph for this caption.)
 1487Title II decision will be in a separate notice.
 1000The other notice with this one is in English/Spanish.
NL 00804.2451598No title II (or additional title II) benefits are payable.
NL 00804.1901310Claimant not eligible for optional State supplement.
NL 00804.1951345Information about category of eligibility claimant filed under or that we did not develop age, disability or blindness.
NL 00804.2202834Value of the one-third reduction (VTR) may not apply if claimant begins to pay pro-rata share of expenses.
NL 00804.1501456Child is age 18 and does not regularly attend school or student child over the age of 18 but under age 22 stops attending school regularly.
NL 00804.2101438Claimant may be overpaid.
NL 00804.1601181Spouse also filed for SSI and will receive a separate notice.
NL 00804.1852489Representative payee will receive a copy of notice.

Appeal rights are preprinted as part of the SSA-L8030-U2 and also appear on the FONS version of the notice.

  1. IF YOU HAVE ANY QUESTIONS (Unnumbered)(Mandatory)

NL ReferenceParagraph 
NL 00804.240MISM53Closing paragraph (Mandatory)
  This caption and the paragraphs under it are not preprinted on the SSA-L8030-U2 so it is important that you add them to the notice. However, they do appear as part of this notice on the FONS version.

2. Signature

Close the notice as follows:

Name of Manager,


3. Enclosures

Two lines under “Title,” at the left margin, type “Enclosure(s)” and list the enclosures, starting a new line for each one.

4. Notice Copies

Two lines under the list of enclosures, at the left margin, type “cc:” if you are sending a copy of the notice to a representative payee, authorized representative and/or legal guardian. List the name(s) of the individual(s) to whom you are sending a copy and under each name list the city and State of the individual's address.

To Link to this section - Use this URL:
NL 00802.025 - Completion of the Manual SSA-L8030-U2, Notice of Disapproved Claim - 08/26/2013
Batch run: 08/26/2013