TN 4 (02-95)

NL 00803.025 Chart of Captions and Paragraphs for Completing the SSA-L8100-U2, SSA-L8151-U2 and SSA-L8155-U2

A. Procedure

The following chart lists the captions and paragraphs to consider when you complete the body of the notice.

NOTE: We labeled the captions with capital letters in alphabetic order as a place-keeping device due to the length of the chart.

Apply the instructions in NL 00802.001B when using this chart.

B. Your payments will be changed as follows

(Mandatory for all SSA-L8155-U2's.)

NL Reference Paragraph Use
NL 00804.115 2019 Tells recipient SSI check will stop or be reduced - Mandatory paragraph for caption.

C. Our decision about how we'll pay you

(Use this caption and the following paragraphs only if the notice addresses a representative payee issue.)

NL Reference Paragraph Use
NL 00804.185 1291 Notices to recipient and representative payee -SSI payments will go to a representative payee.
2290 Notice to recipient - Direct payment to recipient.
2292 Notice to representative payee - New payee selected or direct payment to recipient.
2301 Reporting responsibilities for new representative payee.
2302 Notice to new representative payee - Use of SSI payments.
2294 No SSI payments due now.
NL 00804.200 2600 Drug addiction/alcoholism contributes to recipient's disability- Treatment and representative payee requirements.
2602 Recipient continues to need representative payee.

D. Why your payments changed

(Mandatory caption for all three notices.)

NL Reference Paragraph Use
WITHDRAWAL OR TERMINATION - Use the following paragraphs on the SSA-L8155-U2 to notify a recipient about his/her request for withdrawal or termination of SSI payments:
NL 00804.215 2470 N19 - Request for termination approved.
1503 Provides 60-day notice to recipient to change decision about withdrawal or termination. Use with paragraph 2470 above.
2471 Recipient received SSI payments for termination (N19) month-request for refund. SUSPENSION ACTIONS - Use the following paragraphs to notify a recipient about a suspension action:
NL 00804.175 2523 N01 - Suspension due to excess income.
NL 00804.165 2200 N02 suspension - Recipient is resident of a public institution.
NL 00804.170 2216 N03 suspension - Recipient is outside the U.S.
2219 N13 suspension - Recipient not a U.S. citizen, resident or eligible alien.
NL 00804.180 1272

N04 - Suspension due to excess resources. Use both paragraphs if the recipient does not have a conditional payment agreement.
2285 N04 suspension - Sponsor-to-alien deeming involved.
NL 00804.130 2082 N06 suspension - Failure to file for other benefits.
NL 00804.200 2603 N10/N11 suspension - Recipient not receiving required treatment for drug addiction/alcoholism.
NL 00804.140 2118 N14 suspension - Recipient not age 65 or older.
NL 00804.135 2100 N20 suspension - Recipient failed to furnish a required report or evidence.
NL 00804.190 2325 N52/N53 - Deleted from State rolls for December 1973.
NL 00804.240 2527 S07 suspension - Recipient's SSI check returned for miscellaneous reasons.
NL 00804.185 2291 S08 suspension - Representative payee development pending.
2300 S08 suspension - Recipient newly determined to be a drug addict or alcoholic and payee development is pending.  

REINSTATEMENTS - Use these paragraphs to notify a recipient after a period of suspension that payments will resume:
NL 00804.170 2217 N03 to C01 - Recipient resumes residence in U.S.
NL 00804.180 2284 N04 to C01 - Recipient within resource limits.
2286 N04 to C01 - Sponsor-to-alien deeming involved.
NL 00804.130 2080 N06 to C01 - Recipient has taken steps to file for other benefits.
NL 00804.200 2617 N09 to C01 - Recipient willing to cooperate with vocational rehabilitation agency.
2618 N10/N11 to C01 - Recipient receiving required treatment for drug addiction/alcoholism.
NL 00804.135 2101 N20 to C01 - Recipient provided required report or evidence.

OPTIONAL STATE SUPPLEMENT (OSS) - Consider the following paragraphs if an OSS is an issue:
NL 00804.190 2338 Recipient is not eligible for an OSS payment.
2333 Recipient waived OSS payments.
2310 Recipient moves from State that pays OSS to another OSS State.
2311 Tells recipient effective date of new OSS payments.
2312 Tells recipient effective date former State of residence stops paying OSS.
2317 Tells recipient about change in OSS amount due to State rate change.

MULTICATEGORY ELIGIBILITY (SI 00501.300) - Consider the following paragraphs when multicategory eligibility is an issue:
NL 00804.195 2638 Aged recipient also eligible on basis of disability and/or blindness.
2347 Multicategory eligibility results in increase in OSS payments.
2351 Multicategory eligibility for spouse results in SSI increase.
2346 Recipient or spouse loses eligibility in one or more categories resulting in reduced SSI payment.
2640 Sponsor-to-alien deeming no longer applies - Recipient's date of onset is after date of admission to U.S. for permanent residence. MISCELLANEOUS - The following paragraphs cover a variety of topics:
NL 00804.155 2161 Living arrangement change - Household of another to own household.
NL 00804.225 2371 Appeal pending - Interim change results in change in amount of SSI.
NL 00804.160 2180 Spouse becomes eligible for SSI - Payment decrease for other member of couple.
2181 Spouse's presumptive disability/blindness payments stop - Refigured payment for other member of couple results in increase.
NL 00804.240 2534 Death of eligible spouse, deemor, or sponsor.

E. Information about your payments

(Consider this caption if the notice will include check payment information or if an overpayment, Goldberg-Kelly, or an interim assistance reimbursement (IAR) issue exists.)

NL Reference Paragraph Use
CHECK PAYMENT INFORMATION - Consider the following paragraphs if the notice will have check payment information:
NL 00804.115 1012 Notifies recipient about the retroactive check.
1479 Tells the retroactive check delivery date.
2509 Tells recipient balance due after check adjustment is for a past period.
2510 Tells recipient no additional payment is due for a past period.
2524 Gives check delivery information for the regular monthly check.
2511 Explains underpayment is being withheld to recover an overpayment - states balance of underpayment due to the recipient.
NL 00804.120 2043 Explains that advance payments were recovered. Specifies the ongoing amount due.
2040 Explains that advance payments were made and no additional payments are due now.
NL 00804.235 1014 Explains that proration applies and tells recipient the first day of eligibility.
NL 00804.240 2525 Retroactive change does not affect current payments.
NL 00804.210 2520 First-of-month payment paid in two checks.


OVERPAYMENT - Consider the following paragraphs if there is an overpayment issue:
NL 00804.210 2526 U1 or U2 diary - Notifies recipient about possible underpayment.
2444 Last month of overpayment collection - Regular monthly checks will resume.
2434 Overpayment recovery complete - Regular monthly checks will resume.
2437 Overpayment partially recovered from underpayment - Regular monthly check also reduced.

Overpayment recovery will begin. 10 percent overpayment recovery rate - Ongoing checks due.
1017 10 percent overpayment recovery rate results in withholding of entire check.
1018 Amount of check changes and 10 percent recovery changes.
2042 Overpayment recovery in progress - Subsequent reduction in SSI payments results in withholding of entire SSI payment.
2450 SSI payment change while overpayment recovery is in process.
2455 Living arrangement of overpaid recipient changes to

“D” - Overpayment withholding postponed.

GOLDBERG-KELLY - Consider the following paragraphs if there is a Goldberg-Kelly issue:
NL 00804.225 2021 Next month's check not reduced to allow time to appeal. Use only on the SSA-L8155-U2 after the Goldberg-Kelly cutoff, when appropriate.
2022 Similar to paragraph 2021 above - Overpayment involvement.
2370 Payment continuation pending appeal decision.
2381 Payment stopped - Payment resumed pending outcome of appeal.
2372 Change in payment amount not implemented - Appeal pending.
2375 Appeal pending - Recipient may have to repay incorrect payments.
2373 New determination differs from issue under appeal - Change in SSI payment results.
GBKM01 Appeal pending - Recipient requests payment maintenance - OTP or supplemental payment made.

INTERIM ASSISTANCE REIMBURSEMENT (IAR) - Consider the following paragraphs if there is an IAR issue:
NL 00804.125 1046 Check sent to IAR agency per agreement.
1069 Balance of SSI payments that are not IAR excluded from resources for 6 months.

F. Information about medicaid

(Use this caption before the next caption, “Your SSI Is Based On These Facts,” only when a 1619(b) participant loses 1619(b) status due to excess income other than earned income.)

NL Reference Paragraph Use
NL 00804.250 2053 1619(b) participant will lose Medicaid based on SSI due to loss of 1619(b) status due to computer matching income

(Mandatory paragraph)
2054 State Medicaid office will make final Medicaid decision - Always use this paragraph under paragraph 2053 above.

G. Your (payment/SSI) is based on these facts

(Use this caption when one or more of the paragraphs below is appropriate for explaining the reason for the payment change. When reinstating payments, use all the paragraphs that address facts that affect the payment computation. When the individual is a 1619(b) participant replace “Payment” with “SSI.” )

NL Reference Paragraph Use
NL 00804.215 2473 Recipient revoked request to terminate SSI payments.
NL 00804.145 1130 Correction in category of eligibility.
NL 00804.200 2641 Tells date of onset.
NL 00804.160 1161 Change in spouse's eligibility causes SSI payment to increase or stay the same.
NL 00804.135 PMTM01 Past period of N05 - Unable of confirm eligibility for past nonpay month(s).
NL 00804.170 2218 N13 to C01 - Tells effective date for “color of law” determination.
NL 00804.155 1165 Statement - living arrangement “C” or “D.”
2162 Living arrangement change from “C” or “D” to “A.”
DCMM06 A child can no longer receive SSI based on section 1614(f)(2) of the Act. Explains why he is ineligible.
NL 00804.165 2201 N02 to C01 - Recipient leaves public institution.
NL 00804.190 1312 Change in recipient's county or State of residence causes payment change.

Living arrangement for purpose of optional State supplement. Choose the appropriate paragraph.

INCOME - The following paragraphs address income related issues:
NL 00804.175 1240 Recipient has no income or deemed income.
1601 Change in recipient's or deemor's income does not affect SSI payments.


Choose the appropriate paragraph when windfall offset applies.
1231 Lead-in preceding list of monthly income in paragraph 1232 below.
1232 Describes type, period and amount of countable income.
1253 Recipient received one-time income payment other than SSI. Also use paragraph 1261 (NL 00804.175) if one-time payment will result in N01 suspension for a future month.
1258 Recipient subject to value of the one- third reduction (VTR).
1260 Recipient receives in-kind support and maintenance.
1603 Recipient had net loss from self- employment.
1257 Special income disregards apply.
1602 Student earned income exclusion applies.

DEEMING - Consider the following paragraphs if the claimant is subject to deeming:
1248 Describes type, period and amount of income deemed from spouse or parent(s).
1234 Spouse, parent(s) or sponsor(s) have income deemed to recipient.
1254 Spouse or parent(s) has one-time income payment other than SSI.
2230 Spouse or parent(s) no longer receives public assistance - Deemed income results.
1249 Spouse or parent(s) receive public assistance - No deemed income.
1604 Spouse or parent(s) has net loss from self-employment.

COMPUTER MATCHING - Consider the following paragraphs if computer matching is an issue:
NL 00804.250 2050 Tells recipient about payment reduction and to check computer matching data within 30 days. Use on the SSA-L8155-U2 only.
2051 Tells recipient about payment increase and to check computer matching data within 30 days. Use only on the SSA-L8151-U2.
2052 Payment due increases in the current calendar month of the interface or the supplemental month - FO must issue the additional amount due.  

GRANDFATHERED RECIPIENTS - The following paragraphs address changes that only apply to recipients grandfathered into the SSI program in December 1973. Choose any appropriate paragraphs as follow:
NL 00804.190 2326, 2327, 2328, 2329, 2330, 2318, 2335, 2336 and 2337.

H. Information about your back payments

(Mandatory caption when paragraph 1497 below applies.)

NL Reference Paragraph Use
NL 00804.180 1497 Mandatory paragraph when recipient will receive a retroactive SSI check and there is no IAR involvement, or will receive a retroactive title II check.

I. Our decision on your waiver request

(Use only when paragraph 2439 below applies.)

NL Reference Paragraph Use
NL 00804.210 2439 Waiver request approval. (Mandatory paragraph for this caption.)

J. About your request for direct deposit

(Use only when direct deposit is an issue.)

NL Reference Paragraph Use
NL 00804.230 2772 Recipient requests direct deposit.
2773 Recipient cancels direct deposit.
2774 Recipient changes direct deposit.

Consider the following paragraphs if the recipient's payments are or will be in suspense: 2766, 2767, 2768, 2769, 2770, and 2771.

K. Information about medicaid and other benefits

(Use “AND OTHER BENEFITS” only if paragraph 1311 below will follow. Use this caption only if a change has occurred that may affect Medicaid eligibility.)

NL Reference Paragraph Use
NL 00804.190 1311 Recipient moves to a State that administers its own supplementation program.
NL 00804.110 1150 Recipient moves to a State (or the District of Columbia) for which SSA makes Medicaid determinations.
1156 We are developing for recipient's eligibility under section 1619(b).
1152 or

Recipient resides in or moves to a State where SSA makes Medicaid determinations. Use on the SSA-L8155-U2 when you suspend or terminate SSI payments. Use 1170 instead of 1152 if the recipient resides in Texas.
1154 Change in State of residence - New State of residence makes its own Medicaid determinations.
1146 Recipient did not provide third-party liability (TPL) information.
1149 Recipient did not assign rights to medical support payments to the State.
1143 Notifies title II early widow(er) beneficiaries of possible special Medicaid eligibility. Use this paragraph only on the SSA-L8155-U2. Remember to include the caption labeled K. below and the mandatory paragraph under caption K. when you use this paragraph.
1197 SSI checks have stopped - Recipient may qualify for Medicaid under section 1619(b).
1198 Similar to paragraph 1197 except that State makes Medicaid eligibility determination.
1199 Recipient not eligible for Medicaid based on SSI rules under section 1619(b). (Does not meet use and/or insufficiency tests.)
NL 00804.155 DCMM07 A child is ineligible for SSI because he does not meet the requirements of section 1614(f)(2) of the Act. Tells which State agency can tell him about Medicaid eligibility.

L. Where you can apply for medicaid

(Use only on an SSA-L8155-U2 when you use paragraph 1143 under the preceding caption.)

NL Reference Paragraph Use
NL 00804.110 1144 Notifies title II early widow(er) beneficiaries ineligible for SSI because of their title II income (N01) where to apply for special Medicaid coverage. (Mandatory paragraph for this caption.)

M. Please remember this

(Mandatory caption on SSA-L8155-U2 when a disabled/blind recipient is N01 due to earnings and eligibility under section 1619(b) is an issue or the recipient is ineligible under section 1619(b) because of the use and/or insufficiency of earnings test.)

NL Reference Paragraph Use
The following paragraphs are mandatory when 1619(b) eligibility is an issue.
NL 00804.110 1157 Lead-in for reporting responsibilities when recipient is potentially eligible for Medicaid under section 1619(b).


Reporting responsibilities - use all three paragraphs.

Use the following when the recipient is ineligible under section 1619(b).
1195 Reminder - Recipient should report change(s) by deadline to avoid filing new application.
NL 00804.250 2055 Similar to paragraph 1195 above - Use when computer matching causes 1619(b) participant to lose eligibility.

N. we will review your case

(Use only for section 1619(b) eligibles when paragraph 1190 below applies.)

NL Reference Paragraph Use
NL 00804.110 1190 Information for section 1619(b) eligibles about continuing disability reviews. (Mandatory paragraph for this caption.)

O. Things to remember

(Mandatory caption for all three notices.)

NL Reference Paragraph Use
NL 00804.240 2453 Standard reporting responsibilities. (Mandatory paragraph for recipients in current pay.)
1620 Advises eligible recipient to report changes even though no SSI payments are due now. (Mandatory paragraph when you suspend a recipient's payments.)
1487 Concurrent case - Decision applies only to title XVI.
2750 Determination replaces all previous determinations for period.
2507 Tells recipient to contact SSA if payment still due or if he/she believes she/he can qualify for SSI again.
2508 Similar to paragraph 2507 above - Retroactive payments not an issue.
1481 SSI terminated - Recipient must file new application to qualify.
NL 00804.220 2834 Value of the one-third reduction (VTR) applies - Instructs recipient to contact SSA if he/she begins to share.
NL 00804.195 2352 Aged recipient or aged spouse loses eligibility based on disability or blindness, but SSI eligibility continues for both.
NL 00804.210 1438 Recipient may be overpaid.
NL 00804.190 2331 State countable income (Vermont) changed. Recipient is not currently a resident of Vermont and was not a resident during the period covered by the income change.
NL 00804.200 1619 Treatment requirement - DDS determined drug addiction/ alcoholism now contributes to disability.
NL 00804.180 1270 Payment continuation based on agreement to dispose of excess resources.
NL 00804.185 2489 Representative payee will receive a copy of notice.

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NL 00803.025 - Chart of Captions and Paragraphs for Completing the SSA-L8100-U2, SSA-L8151-U2 and SSA-L8155-U2 - 02/16/1995
Batch run: 09/19/2012