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 ReferenceParagraphUse
NL 00804.1152019Tells 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 ReferenceParagraphUse
NL 00804.1851291Notices to recipient and representative payee -SSI payments will go to a representative payee.
2290Notice to recipient - Direct payment to recipient.
2292Notice to representative payee - New payee selected or direct payment to recipient.
2301Reporting responsibilities for new representative payee.
2302Notice to new representative payee - Use of SSI payments.
2294No SSI payments due now.
NL 00804.2002600Drug addiction/alcoholism contributes to recipient's disability- Treatment and representative payee requirements.
2602Recipient continues to need representative payee.

D. Why your payments changed

(Mandatory caption for all three notices.)

NL ReferenceParagraphUse
  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 00804.2152470N19 - Request for termination approved.
1503Provides 60-day notice to recipient to change decision about withdrawal or termination. Use with paragraph 2470 above.
2471Recipient 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 00804.1752523N01 - Suspension due to excess income.
NL 00804.1652200N02 suspension - Recipient is resident of a public institution.
NL 00804.1702216N03 suspension - Recipient is outside the U.S.
2219N13 suspension - Recipient not a U.S. citizen, resident or eligible alien.
NL 00804.1801272
N04 - Suspension due to excess resources. Use both paragraphs if the recipient does not have a conditional payment agreement.
2285N04 suspension - Sponsor-to-alien deeming involved.
NL 00804.1302082N06 suspension - Failure to file for other benefits.
NL 00804.2002603N10/N11 suspension - Recipient not receiving required treatment for drug addiction/alcoholism.
NL 00804.1402118N14 suspension - Recipient not age 65 or older.
NL 00804.1352100N20 suspension - Recipient failed to furnish a required report or evidence.
NL 00804.1902325N52/N53 - Deleted from State rolls for December 1973.
NL 00804.2402527S07 suspension - Recipient's SSI check returned for miscellaneous reasons.
NL 00804.1852291S08 suspension - Representative payee development pending.
2300S08 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 00804.1702217N03 to C01 - Recipient resumes residence in U.S.
NL 00804.1802284N04 to C01 - Recipient within resource limits.
2286N04 to C01 - Sponsor-to-alien deeming involved.
NL 00804.1302080N06 to C01 - Recipient has taken steps to file for other benefits.
NL 00804.2002617N09 to C01 - Recipient willing to cooperate with vocational rehabilitation agency.
2618N10/N11 to C01 - Recipient receiving required treatment for drug addiction/alcoholism.
NL 00804.1352101N20 to C01 - Recipient provided required report or evidence.
OPTIONAL STATE SUPPLEMENT (OSS) - Consider the following paragraphs if an OSS is an issue:
NL 00804.1902338Recipient is not eligible for an OSS payment.
2333Recipient waived OSS payments.
2310Recipient moves from State that pays OSS to another OSS State.
2311Tells recipient effective date of new OSS payments.
2312Tells recipient effective date former State of residence stops paying OSS.
2317Tells 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 00804.1952638Aged recipient also eligible on basis of disability and/or blindness.
2347Multicategory eligibility results in increase in OSS payments.
2351Multicategory eligibility for spouse results in SSI increase.
2346Recipient or spouse loses eligibility in one or more categories resulting in reduced SSI payment.
2640Sponsor-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 00804.1552161Living arrangement change - Household of another to own household.
NL 00804.2252371Appeal pending - Interim change results in change in amount of SSI.
NL 00804.1602180Spouse becomes eligible for SSI - Payment decrease for other member of couple.
2181Spouse's presumptive disability/blindness payments stop - Refigured payment for other member of couple results in increase.
NL 00804.2402534Death 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 ReferenceParagraphUse
  CHECK PAYMENT INFORMATION - Consider the following paragraphs if the notice will have check payment information:
NL 00804.1151012Notifies recipient about the retroactive check.
1479Tells the retroactive check delivery date.
2509Tells recipient balance due after check adjustment is for a past period.
2510Tells recipient no additional payment is due for a past period.
2524Gives check delivery information for the regular monthly check.
2511Explains underpayment is being withheld to recover an overpayment - states balance of underpayment due to the recipient.
NL 00804.1202043Explains that advance payments were recovered. Specifies the ongoing amount due.
2040Explains that advance payments were made and no additional payments are due now.
NL 00804.2351014Explains that proration applies and tells recipient the first day of eligibility.
NL 00804.2402525Retroactive change does not affect current payments.
NL 00804.2102520First-of-month payment paid in two checks.
OVERPAYMENT - Consider the following paragraphs if there is an overpayment issue:
NL 00804.2102526U1 or U2 diary - Notifies recipient about possible underpayment.
2444Last month of overpayment collection - Regular monthly checks will resume.
2434Overpayment recovery complete - Regular monthly checks will resume.
2437Overpayment partially recovered from underpayment - Regular monthly check also reduced.
Overpayment recovery will begin. 10 percent overpayment recovery rate - Ongoing checks due.
101710 percent overpayment recovery rate results in withholding of entire check.
1018Amount of check changes and 10 percent recovery changes.
2042Overpayment recovery in progress - Subsequent reduction in SSI payments results in withholding of entire SSI payment.
2450SSI payment change while overpayment recovery is in process.
2455Living arrangement of overpaid recipient changes to
“D” - Overpayment withholding postponed.
GOLDBERG-KELLY - Consider the following paragraphs if there is a Goldberg-Kelly issue:
NL 00804.2252021Next month's check not reduced to allow time to appeal. Use only on the SSA-L8155-U2 after the Goldberg-Kelly cutoff, when appropriate.
2022Similar to paragraph 2021 above - Overpayment involvement.
2370Payment continuation pending appeal decision.
2381Payment stopped - Payment resumed pending outcome of appeal.
2372Change in payment amount not implemented - Appeal pending.
2375Appeal pending - Recipient may have to repay incorrect payments.
2373New determination differs from issue under appeal - Change in SSI payment results.
GBKM01Appeal 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 00804.1251046Check sent to IAR agency per agreement.
1069Balance 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 ReferenceParagraphUse
NL 00804.25020531619(b) participant will lose Medicaid based on SSI due to loss of 1619(b) status due to computer matching income
(Mandatory paragraph)
2054State 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 ReferenceParagraphUse
NL 00804.2152473Recipient revoked request to terminate SSI payments.
NL 00804.1451130Correction in category of eligibility.
NL 00804.2002641Tells date of onset.
NL 00804.1601161Change in spouse's eligibility causes SSI payment to increase or stay the same.
NL 00804.135PMTM01Past period of N05 - Unable of confirm eligibility for past nonpay month(s).
NL 00804.1702218N13 to C01 - Tells effective date for “color of law” determination.
NL 00804.1551165Statement - living arrangement “C” or “D.”
2162Living arrangement change from “C” or “D” to “A.”
DCMM06A child can no longer receive SSI based on section 1614(f)(2) of the Act. Explains why he is ineligible.
NL 00804.1652201N02 to C01 - Recipient leaves public institution.
NL 00804.1901312Change 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 00804.1751240Recipient has no income or deemed income.
1601Change in recipient's or deemor's income does not affect SSI payments.
Choose the appropriate paragraph when windfall offset applies.
1231Lead-in preceding list of monthly income in paragraph 1232 below.
1232Describes type, period and amount of countable income.
1253Recipient 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.
1258Recipient subject to value of the one- third reduction (VTR).
1260Recipient receives in-kind support and maintenance.
1603Recipient had net loss from self- employment.
1257Special income disregards apply.
1602Student earned income exclusion applies.
DEEMING - Consider the following paragraphs if the claimant is subject to deeming:
1248Describes type, period and amount of income deemed from spouse or parent(s).
1234Spouse, parent(s) or sponsor(s) have income deemed to recipient.
1254Spouse or parent(s) has one-time income payment other than SSI.
2230Spouse or parent(s) no longer receives public assistance - Deemed income results.
1249Spouse or parent(s) receive public assistance - No deemed income.
1604Spouse or parent(s) has net loss from self-employment.
COMPUTER MATCHING - Consider the following paragraphs if computer matching is an issue:
NL 00804.2502050Tells recipient about payment reduction and to check computer matching data within 30 days. Use on the SSA-L8155-U2 only.
2051Tells recipient about payment increase and to check computer matching data within 30 days. Use only on the SSA-L8151-U2.
2052Payment 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 ReferenceParagraphUse
NL 00804.1801497Mandatory 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 ReferenceParagraphUse
NL 00804.2102439Waiver request approval. (Mandatory paragraph for this caption.)

J. About your request for direct deposit

(Use only when direct deposit is an issue.)

NL ReferenceParagraphUse
NL 00804.2302772Recipient requests direct deposit.
2773Recipient cancels direct deposit.
2774Recipient 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 ReferenceParagraphUse
NL 00804.1901311Recipient moves to a State that administers its own supplementation program.
NL 00804.1101150Recipient moves to a State (or the District of Columbia) for which SSA makes Medicaid determinations.
1156We 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.
1154Change in State of residence - New State of residence makes its own Medicaid determinations.
1146Recipient did not provide third-party liability (TPL) information.
1149Recipient did not assign rights to medical support payments to the State.
1143Notifies 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.
1197SSI checks have stopped - Recipient may qualify for Medicaid under section 1619(b).
1198Similar to paragraph 1197 except that State makes Medicaid eligibility determination.
1199Recipient not eligible for Medicaid based on SSI rules under section 1619(b). (Does not meet use and/or insufficiency tests.)
NL 00804.155DCMM07A 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 ReferenceParagraphUse
NL 00804.1101144Notifies 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 ReferenceParagraphUse
  The following paragraphs are mandatory when 1619(b) eligibility is an issue.
NL 00804.1101157Lead-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).
1195Reminder - Recipient should report change(s) by deadline to avoid filing new application.
NL 00804.2502055Similar 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 ReferenceParagraphUse
NL 00804.1101190Information 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 ReferenceParagraphUse
NL 00804.2402453Standard reporting responsibilities. (Mandatory paragraph for recipients in current pay.)
1620Advises eligible recipient to report changes even though no SSI payments are due now. (Mandatory paragraph when you suspend a recipient's payments.)
1487Concurrent case - Decision applies only to title XVI.
2750Determination replaces all previous determinations for period.
2507Tells recipient to contact SSA if payment still due or if he/she believes she/he can qualify for SSI again.
2508Similar to paragraph 2507 above - Retroactive payments not an issue.
1481SSI terminated - Recipient must file new application to qualify.
NL 00804.2202834Value of the one-third reduction (VTR) applies - Instructs recipient to contact SSA if he/she begins to share.
NL 00804.1952352Aged recipient or aged spouse loses eligibility based on disability or blindness, but SSI eligibility continues for both.
NL 00804.2101438Recipient may be overpaid.
NL 00804.1902331State 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 00804.2001619Treatment requirement - DDS determined drug addiction/ alcoholism now contributes to disability.
NL 00804.1801270Payment continuation based on agreement to dispose of excess resources.
NL 00804.1852489Representative payee will receive a copy of notice.

To Link to this section - Use this URL:
NL 00803.025 - Chart of Captions and Paragraphs for Completing the SSA-L8100-U2, SSA-L8151-U2 and SSA-L8155-U2 - 09/19/2012
Batch run: 09/19/2012