TN 23 (04-94)
NL 00804.175 Income -- SSI Paragraphs
1231. Situation Where Used:
IC: Award—chargeable income to be counted.
PE: Change in income.
(1) (2) monthly income which must be considered in figuring (3) payment as follows—
Fill-ins:
-
(1)
Choice 1 - You
Choice 2 - She
Choice 3 - He
-
(2)
Choice 1 - have
Choice 2 - has
Choice 3 - had
-
(3)
Choice 1 - your
Choice 2 - her
Choice 3 - his
1232. Situation Where Used:
IC: Specific type, amount, and period of countable income.
PE: Change in income.
(1) (2) of (3) (4) (5)
Fill-ins:
-
(1)
Choice 1 - Your
Choice 2 - Her
Choice 3 - His
Choice 4 - The
-
(2)
Choice 1 - wages
Choice 2 - Social Security benefits—before deductions for Medicare Medical insurance
premiums,
Choice 3 - railroad retirement benefits—before deductions for Medicare premiums, if
any
Choice 4 - black lung benefits
Choice 5 - Veterans Administration compensation
Choice 6 - workmen's compensation
Choice 7 - Veterans Administration pension
Choice 8 - employment related pension
Choice 9 - assistance payments based on need
Choice 10 - rents, interest, dividends, or royalties
Choice 11 - civil service pension
Choice 12 - other unearned income
Choice 13 - support payments from parent
Choice 14 - military pension
Choice 15 - net income from self-employment
Choice 16 - net loss from self-employment
Choice 17 - income of your sponsor
Choice 18 - income of her sponsor
Choice 19 - income of his sponsor
Choice 20 - income of your sponsor and the spouse of your sponsor
Choice 21 - income of her sponsor and the spouse of her sponsor
Choice 22 - income of his sponsor and the spouse of his sponsor
Choice 23 - Social Security benefits—before deductions for Medicare premiums, if any—
Choice 24 - railroad retirement benefits—before any deductions for Medicare premiums—
-
-
(4)
Choice 1 - for (Month/Year)
Choice 2 - for (Month/Year) through (Month/Year)
Choice 3 - for (Month/Year) on
Choice 4 - or less for (Month/Year)
Choice 5 - or less for (Month/Year) through (Month/Year)
Choice 6 - or less for (Month/Year) on
-
(5)
Choice 1 - ,
Choice 2 - and
Choice 3 - .
NOTE: Repeat fill-ins as needed.
1234. Situation Where Used:
IC: Individual has deemed countable income.
PE: Change in income.
The income of (1) (2) which is counted as (3) income of (4) (5) (6)
Fill-ins:
-
(1)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(2)
Choice 1 - spouse
Choice 2 - parent
Choice 3 - parents
Choice 4 - sponsor
Choice 5 - sponsor and the spouse of your sponsor
Choice 6 - sponsor and the spouse of her sponsor
Choice 7 - sponsor and the spouse of his sponsor
-
(3)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
-
(5)
Choice 1 - for (Month/Year)
Choice 2 - for (Month/Year) through (Month/Year)
Choice 3 - for (Month/Year) on
-
(6)
Choice 1 - ,
Choice 2 - and
Choice 3 - .
NOTE: Fill-ins 2-6 repeat as needed.
1235. Situation Where Used:
IC: Individual receives support and maintenance.
PE: Change in income.
NOTE: OBSOLETE—(Replaced by 1260, July 15, 1986.)
Support and maintenance (1) received which we value at (2) (3) (4)
Fill-ins:
-
(1)
Choice 1 - you
Choice 2 - she
Choice 3 - he
Choice 4 - your spouse
Choice 5 - her spouse
Choice 6 - his spouse
-
-
(3)
Choice 1 - for (Month/Year)
Choice 2 - for (Month/Year) through (Month/Year)
Choice 3 - for (Month/Year) on
-
(4)
Choice 1 - ,
Choice 2 - and
Choice 3 - .
NOTE: Fill-ins 2-4 repeat as needed.
1239. Situation Where Used:
IC: Denial for excess income.
PE: Suspension due to excess income.
Because of (1) income, (2) not eligible to receive Supplemental Security Income payments (3) (4)
Fill-ins:
-
(1)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(2)
Choice 1 - you are
Choice 2 - you were
Choice 3 - she is
Choice 4 - she was
Choice 5 - he is
Choice 6 - he was
-
(3)
Choice 1 - for (Month/Year)
Choice 2 - for (Month/Year) through (Month/Year)
Choice 3 - for (Month/Year) on
-
(4)
Choice 1 - ,
Choice 2 - and
Choice 3 - .
NOTE: Fill-ins 3 and 4 repeat as needed.
1240. Situation Where Used:
Award—no countable income.
PE: For 1 or more months covered and there is no income on the record.
(1) (2) no income (3) (4)
Fill-ins:
-
(1)
Choice 1 - You
Choice 2 - You and your parent
Choice 3 - You and your parents
Choice 4 - You and your spouse
Choice 5 - Your parent
Choice 6 - Your parents
Choice 7 - Your spouse
Choice 8 - She
Choice 9 - She and her parent
Choice 10 - She and her parents
Choice 11 - She and her spouse
Choice 12 - Her parent
Choice 13 - Her parents
Choice 14 - Her spouse
Choice 15 - He
Choice 16 - He and his parent
Choice 17 - He and his parents
Choice 18 - He and his spouse
Choice 19 - His parent
Choice 20 - His parents
Choice 21 - His spouse
Choice 22 - Your sponsor
Choice 23 - Your sponsor and the spouse of your sponsor
Choice 24 - You, your sponsor, and the spouse of your sponsor
Choice 25 - Her sponsor
Choice 26 - Her sponsor and the spouse of her sponsor
Choice 27 - She, her spouse, and the spouse of her sponsor
Choice 28 - His sponsor
Choice 29 - His sponsor and the spouse of his sponsor
Choice 30 - He, his sponsor, and the spouse of his sponsor
Choice 31 - You and your sponsor
Choice 32 - She and her sponsor
Choice 33 - He and his sponsor
-
(2)
Choice 1 - have
Choice 2 - has
Choice 3 - had
-
(3)
Choice 1 - for (Month/Year)
Choice 2 - for (Month/Year) through (Month/Year)
Choice 3 - for (Month/Year) on
-
(4)
Choice 1 - ,
Choice 2 - and
Choice 3 - .
NOTE: Repeat fill-ins as needed.
1244. Situation Where Used:
Denial—amount and type of special disregards.
In determining (1) eligibility, (2) disregarded as follows— (3) (4) (5)
Fill-ins:
-
(1)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(2)
Choice 1 - earned income as a student was
Choice 2 - income to fulfill a plan to achieve self-support was
Choice 3 - income used to meet work expenses was
Choice 4 - income used to meet impairment-related work expenses was
-
-
(4)
Choice 1 - for (Month/Year)
Choice 2 - for (Month/Year) through (Month/Year)
Choice 3 - for (Month/Year) on
-
(5)
Choice 1 - ,
Choice 2 - and
Choice 3 - .
Choice 4 - , and $$$.¢¢for (Month/Year)
Choice 5 - , and $$$.¢¢for (Month/Year) through (Month/Year)
Choice 6 - , and $$$.¢¢for (Month/Year) on
NOTE: Repeat fill-ins 2-5 as needed.
1245. Situation Where Used:
Denial for excess income—ineligible spouse or parent receives public assistance.
The income of (1) (2) does not affect (3) eligibility for Supplemental Security Income because (4) (5) public assistance.
Fill-ins:
-
(1)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(2)
Choice 1 - parent
Choice 2 - parents
Choice 3 - spouse
-
(3)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(4)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(5)
Choice 1 - parent receives
Choice 2 - parents receive
Choice 3 - spouse receives
1248. Situation Where Used:
IC: Award—amount and type of income received by spouse or parents.
PE: Change in income. Record shows deemed income for 1 or more months.
The (1) received by (2) of (3) (4) (5)
Fill-ins:
-
(1)
Choice 1 - wages
Choice 2 - Social Security benefits—before any deduction for Medicare Medical Insurance
premiums—
Choice 3 - railroad retirement benefits—before any deduction for Medicare Medical
Insurance premiums —
Choice 4 - black lung benefits
Choice 5 - Veterans Administration compensation
Choice 6 - workmen's compensation
Choice 7 - Veterans Administration pension
Choice 8 - employment related pension
Choice 9 - assistance payments based on need
Choice 10 - rents, interest, dividends, or royalties
Choice 11 - civil service pension
Choice 12 - other unearned income
Choice 13 - support payments from parent
Choice 14 - military pension
Choice 15 - net income from self-employment
Choice 16 - net loss from self-employment
Choice 17 - Social Security benefits—before deductions for Medicare premiums, if any—
Choice 18 - railroad retirements benefits—before any deductions for Medicare premiums—
-
(2)
Choice 1 - your parent
Choice 2 - your parents
Choice 3 - your spouse
Choice 4 - her parent
Choice 5 - her parents
Choice 6 - her spouse
Choice 7 - his parent
Choice 8 - his parents
Choice 9 - his spouse
Choice 10 - (Name of essential person)
-
-
(4)
Choice 1 - for (Month/Year)
Choice 2 - for (Month/Year) through (Month/Year)
Choice 3 - for (Month/Year) on
Choice 4 - or less for (Month/Year)
Choice 5 - or less for (Month/Year) through (Month/Year)
Choice 6 - or less for (Month/Year) on
-
(5)
Choice 1 - ,
Choice 2 - and
Choice 3 - .
NOTE: Fill-ins 3-5 repeat as needed.
1249. Situation Where Used:
IC: Exclusion of income of spouse or parents receiving public assistance.
PE: Change in income. Spouse or parent received public assistance for 1 or more months.
The income of (1) (2) does not affect (3) eligibility for Supplemental Security Income payments because (4) (5) public assistance (6) (7)
Fill-ins:
-
(1)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(2)
Choice 1 - parent
Choice 2 - parents
Choice 3 - spouse
-
(3)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(4)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(5)
Choice 1 - parent receives
Choice 2 - parents receive
Choice 3 - spouse receives
Choice 4 - parent received
Choice 5 - parents received
Choice 6 - spouse received
-
(6)
Choice 1 - for (Month/Year)
Choice 2 - for (Month/Year) through (Month/Year)
Choice 3 - for (Month/Year) on
-
(7)
Choice 1 - ,
Choice 2 - and
Choice 3 - .
NOTE: Fill-ins 6 and 7 repeat as needed.
1252. Situation Where Used:
IC and PE: This paragraph will be produced following all other income paragraphs whenever
paragraphs for unearned income types A, C, E, and/or M are produced.
PE: Change in income.
We must count the full amount of any benefit listed above as income even though all
or part of a benefit shown is being withheld to recover an overpayment.
1253. Situation Where Used:
IC and PE: Countable income includes special one-time payment for 1 or more months.
PE: Change in income.
NOTE: This replaces paragraph 1246.
(1) special one-time payment (2) received (3) of (4) (5) .
Fill-ins:
-
(1)
Choice 1 - Your
Choice 2 - Her
Choice 3 - His
-
(2)
Choice 1 - of Social Security benefits—before deduction for Medicare Medical Insurance
premiums,—
Choice 2 - of railroad retirement benefits—before deduction for Medicare Medical Insurance
premiums,—
Choice 3 - of black lung benefits
Choice 4 - of Veterans Administration compensation
Choice 5 - of workmen's compensation
Choice 6 - of Veterans Administration pension
Choice 7 - of employment related pension
Choice 8 - of assistance payments based on need
Choice 9 - of rents, interest, dividends, or royalties
Choice 10 - of civil service pension
Choice 11 - of other unearned income
Choice 12 - of support payment from parent
Choice 13 - of military pension
Choice 14 - of support and maintenance
Choice 15 - of Social Security benefits—before deductions for Medicare premiums, if
any
Choice 16 - of railroad retirement benefits—before any deductions for Medicare premiums—
Choice 17 - Null
-
-
-
(5)
Choice 1 - ,
Choice 2 - and
Choice 3 - .
NOTE: Fill-in 2-5 repeat as needed.
1254. Situation Where Used:
IC and PE: Countable income includes special one-time payment received by spouse,
parent(s), or essential person for 1 or more months.
PE: Change in income.
NOTE: This replaces paragraph 1247.
(1) , the special one-time payment (2) received by (3) (4) .
Fill-ins:
-
-
(2)
Choice 1 - of Social Security benefits—before deduction for Medicare Medical Insurance
premiums,—
Choice 2 - of railroad retirement benefits—before deduction for Medicare Medical Insurance
premiums,—
Choice 3 - of black lung benefits
Choice 4 - of Veterans Administration compensation
Choice 5 - of workmen's compensation
Choice 6 - of Veterans Administration pension
Choice 7 - of employment related pension
Choice 8 - of assistance payments based on need
Choice 9 - of rents, interest, dividends, or royalties
Choice 10 - of civil service pension
Choice 11 - of other unearned income
Choice 12 - of support payment from parent
Choice 13 - of military pension
Choice 14 - of support and maintenance
Choice 15 - of Social Security benefits—before deduction for Medicare premiums, if
any
Choice 16 - of railroad retirement benefits—before any deductions for Medicare premiums—
Choice 17 - Null
-
(3)
Choice 1 - your parent
Choice 2 - your parents
Choice 3 - your spouse
Choice 4 - her parent
Choice 5 - her parents
Choice 6 - her spouse
Choice 7 - his parent
Choice 8 - his parents
Choice 9 - his spouse
Choice 10 - (name of essential person)
-
1257. Situation Where Used:
IC and PE: Income disregards applied for 1 or more months.
PE: Change in income.
In figuring (1) payment (2) (3) was disregarded as follows— (4) (5) (6)
Fill-ins:
-
(1)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(2)
Choice 1 - your
Choice 2 - her
Choice 3 - his
Choice 4 - your spouse
Choice 5 - her spouse
Choice 6 - his spouse
Choice 7 - your parents
Choice 8 - her parents
Choice 9 - his parents
-
(3)
Choice 1 - earned income as a student
Choice 2 - income to fulfill a plan to achieve self-support
Choice 3 - income to meet work expenses
Choice 4 - income used to meet impairment-related work expenses
Choice 5 - living allowance for ineligible children
-
-
(5)
Choice 1 - for (Month/Year)
Choice 2 - for (Month/Year) through (Month/Year)
Choice 3 - for each month, beginning (Month/Year)
-
(6)
Choice 1 - ,
Choice 2 - and
Choice 3 - .
NOTE: Repeat fill-ins 4, 5 and 6 as needed.
1258. Situation Where Used:
IC and PE: Used to show periods when the individual is subject to the statutory one-third
reduction.
The food and shelter (1) (2) in someone else's home or apartment. We value that food and shelter at (3) (4) (5) .
Fill-ins:
-
(1)
Choice 1 - you
Choice 2 - she
Choice 3 - he
Choice 4 - your spouse
Choice 5 - her spouse
Choice 6 - his spouse
Choice 7 - you and your spouse
Choice 8 - she and her spouse
Choice 9 - he and his spouse
-
(2)
Choice 1 - get
Choice 2 - gets
Choice 3 - got
-
(3)
$$$.¢¢(Amount of type J unearned income)
-
(4)
Choice 1 - for (Month/Year)
Choice 2 - for (Month/Year) through (Month/Year)
Choice 3 - for (Month/Year) on
-
(5)
Choice 1 - ,
Choice 2 - and
Choice 3 - .
1259. Situation Where Used:
IC and PE: Used to inform the recipient in FLA-B that he/she may be entitled to more
money if they are paying their share of the household expenses.
(1) SSI payment has been reduced by (2) (3) . We have done this because (4) share of the household expenses. Contact us if you think (5) share. We may be able to pay (6) more money.
Fill-ins:
-
(1)
Choice 1 - Your
Choice 2 - Her
Choice 3 - His
-
(2)
$$$.¢¢(Amount of type J unearned income)
-
(3)
Choice 1 - for (Month/Year)
Choice 2 - for (Month/Year) through (Month/Year)
Choice 3 - for (Month/Year) on
-
(4)
Choice 1 - you live in someone else's house or apartment and are not paying your
Choice 2 - she lives in someone else's house or apartment and is not paying her
Choice 3 - he lives in someone else's house or apartment and is not paying his
-
(5)
Choice 1 - you are paying your
Choice 2 - she is paying her
Choice 3 - he is paying his
-
(6)
Choice 1 - you
Choice 2 - her
Choice 3 - him
1260. Situation Where Used:
IC and PE: Used to tell the recipient and/or his/her spouse what in-kind support and
maintenance is charged as income to a recipient in FLA-A.
The food, clothing or shelter (1) (2) from someone. We value the food, clothing or shelter at (3) (4) (5) .
Fill-ins:
-
(1)
Choice 1 - you
Choice 2 - she
Choice 3 - he
Choice 4 - your spouse
Choice 5 - her spouse
Choice 6 - his spouse
Choice 7 - you and your spouse
Choice 8 - she and her spouse
Choice 9 - he and his spouse
-
(2)
Choice 1 - get
Choice 2 - gets
Choice 3 - got
-
(3)
$$$.¢¢(Amount of type H income)
-
(4)
Choice 1 - for (Month/Year)
Choice 2 - for (Month/Year) through (Month/Year)
Choice 3 - for (Month/Year) on
-
(5)
Choice 1 - ,
Choice 2 - and
Choice 3 - .
1261. Situation Where Used:
One-time payment is involved in NO1 decision which results in payment suspension for
a future month. Since the system does not compute payment beyond CCM, the system cannot
tell whether eligibility will resume in the month CCM +1.
However, (1) may be able to get SSI again as soon as (2) . If (3) not hear from us about this in the next 30 days, contact our nearest office. If (4) not get a check, we will be able to tell (5) why. And if (6) we are wrong, (7) can ask us to review our decision.
Fill-ins:
-
(1)
Choice 1 - you
Choice 2 - she
Choice 3 - he
-
-
(3)
Choice 1 - you do
Choice 2 - she does
Choice 3 - he does
-
(4)
Choice 1 - you do
Choice 2 - she does
Choice 3 - he does
-
(5)
Choice 1 - you
Choice 2 - her
Choice 3 - him
-
(6)
Choice 1 - you think
Choice 2 - she thinks
Choice 3 - he thinks
-
(7)
Choice 1 - you
Choice 2 - she
Choice 3 - he
1280. Situation Where Used:
IC and PE situations when the retroactive title II check has been issued and it includes
payment only for the windfall offset period.
We use (1) Social Security money of (2) , which (3) got in (4) , to figure (5) SSI payment. We count (6) Social Security money as if we paid it to (7) during each month it was due. This means we count the money as (8) (9) (10) . These are the amounts before deductions for Medicare premiums, if any.
Fill-ins:
-
(1)
Choice 1 - your
Choice 2 - her
Choice 3 - his
Choice 4 - the
-
-
(3)
Choice 1 - you
Choice 2 - she
Choice 3 - he
Choice 4 - your spouse
Choice 5 - her spouse
Choice 6 - his spouse
-
-
(5)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(6)
Choice 1 - your
Choice 2 - her
Choice 3 - his
Choice 4 - the
-
(7)
Choice 1 - you
Choice 2 - her
Choice 3 - him
Choice 4 - your spouse
Choice 5 - her spouse
Choice 6 - his spouse
-
-
(9)
Choice 1 - for (Month/Year)
Choice 2 - a month for (Month/Year) and (Month/Year)
Choice 3 - a month for (Month/Year) through (Month/Year)
-
(10)
Choice 1 - ,
Choice 2 - and
Choice 3 - .
NOTE: Fill-ins 8, 9 and 10 are used in conjunction with each other to address all the
necessary variations when the retroactive title II amounts differ from month to month.
For example: (1) $200 a month for June through September 1985; or
(2) $200 a month for June 1985, $210 for July 1985, $205 a month for August
and September 1985,
$207 a month for October through December 1985, and $215 for January
1986.
1281. Situation Where Used:
IC and PE: The retroactive title II check has been issued. Refers only to title II
amounts due for the windfall offset period.
(1) will soon get Social Security money for past months. When we figure (2) SSI payments, we count this Social Security money as if we paid it to (3) during each of the months it was due. (4) due (5) (6) (7)
Fill-ins:
-
(1)
Choice 1 - You
Choice 2 - She
Choice 3 - He
Choice 4 - Your spouse
Choice 5 - Her spouse
Choice 6 - His spouse
-
(2)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(3)
Choice 1 - you
Choice 2 - her
Choice 3 - him
Choice 4 - your spouse
Choice 5 - her spouse
Choice 6 - his spouse
-
(4)
Choice 1 - You were
Choice 2 - She was
Choice 3 - He was
Choice 4 - Your spouse was
Choice 5 - Her spouse was
Choice 6 - His spouse was
-
-
(6)
Choice 1 - for (Month/Year)
Choice 2 - a month for (Month/Year) and (Month/Year)
Choice 3 - a month for (Month/Year) through (Month/Year)
-
(7)
Choice 1 - ,
Choice 2 - and
Choice 3 - .
NOTE: Fill-ins 5, 6 and 7 are used in conjunction with each other to address all the necessary
variations required when the retroactive title II amounts differ from month to month.
For example: (1) $200 a month for June through September 1985; or
(2) $200 a month for June 1985, $210 for July 1985, $205 a month for August
and September 1985,
$207 a month for October through December 1985, and $215 for January
1986.
1282. Situation Where Used:
IC and PE: When the title II retroactive check has been issued and it includes money
for months outside the offset period.
IC: It is used with both allowance and denial notices.
PE: This paragraph is generated only once—the month in which the retroactive title
II check for the offset period is issued.
We use (1) Social Security money of (2) , which (3) got in (4) , to figure (5) SSI payment. We count the Social Security money (6) got for months before (7) , which was the first month (8) could get SSI, as income in the month (9) got it. Starting with (10) , we count the money as if we paid it to (11) during the month it was due. This means we count the Social Security money as (12) (13) (14) . These are the amounts before deductions for Medicare premiums, if any.
Fill-ins:
-
(1)
Choice 1 - your
Choice 2 - her
Choice 3 - his
Choice 4 - the
-
(2)
$$$.¢¢(Amount of the title II retroactive check. This check may include a CMA amount
also.)
-
(3)
Choice 1 - you
Choice 2 - she
Choice 3 - he
Choice 4 - your spouse
Choice 5 - her spouse
Choice 6 - his spouse
-
-
(5)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(6)
Choice 1 - you
Choice 2 - she
Choice 3 - he
Choice 4 - your spouse
Choice 5 - her spouse
Choice 6 - his spouse
-
(7)
(Month/Year) (first month of SSI eligibility)
-
(8)
Choice 1 - you
Choice 2 - she
Choice 3 - he
-
(9)
Choice 1 - you
Choice 2 - she
Choice 3 - he
Choice 4 - your spouse
Choice 5 - her spouse
Choice 6 - his spouse
-
(10)
(Month/Year) (same as #7)
-
(11)
Choice 1 - you
Choice 2 - her
Choice 3 - him
Choice 4 - your spouse
Choice 5 - her spouse
Choice 6 - his spouse
-
-
(13)
Choice 1 - for (Month/Year)
Choice 2 - a month for (Month/Year) and (Month/Year)
Choice 3 - a month for (Month/Year) through (Month/Year)
-
(14)
Choice 1 - ,
Choice 2 - and
Choice 3 - .
NOTE: Fill-ins 12, 13 and 14 are used in conjunction with each other to address all the
necessary variations required when the retroactive title II amounts differ from month
to month. The total income addressed in these fill-ins will equal the amount of the
retroactive money given in fill-in 2 above.
For example: (1) $200 a month for June through September 1985; or
(2) $200 a month for June 1985, $210 for July 1985, $205 a month for August
and September 1985,
$207 a month for October through December 1985, and $215 for January
1986.
1601. Situation Where Used:
IC: Award—amount of chargeable income reduced to zero because of disregards.
PE: Change in income, but no change in payment amount because after exclusions are
subtracted, chargeable income remains at zero.
(1) (2) monthly income of (3) (4) (5) . This amount does not affect (6) Supplemental Security Income payment.
Fill-ins:
-
(1)
Choice 1 - You
Choice 2 - You and your parent
Choice 3 - You and your parents
Choice 4 - You and your spouse
Choice 5 - Your parent
Choice 6 - Your parents
Choice 7 - Your spouse
Choice 8 - She
Choice 9 - She and her parent
Choice 10 - She and her parents
Choice 11 - She and her spouse
Choice 12 - Her parent
Choice 13 - Her parents
Choice 14 - Her spouse
Choice 15 - He
Choice 16 - He and his parent
Choice 17 - He and his parents
Choice 18 - He and his spouse
Choice 20 - His parent
Choice 21 - His parents
Choice 22 - His spouse
Choice 23 - Your sponsor
Choice 24 - Her sponsor
Choice 25 - His sponsor
Choice 26 - You and your sponsor
Choice 27 - She and her sponsor
Choice 28 - He and his sponsor
Choice 29 - Your sponsor and the spouse of your sponsor
Choice 30 - Her sponsor and the spouse of her sponsor
Choice 31 - His sponsor and the spouse of his sponsor
Choice 32 - You, your sponsor, and the spouse of your sponsor
Choice 33 - She, her sponsor, and the spouse of her sponsor
Choice 34 - He, his sponsor, and the spouse of his sponsor
-
(2)
Choice 1 - have
Choice 2 - has
Choice 3 - had
-
-
(4)
Choice 1 - for (Month/Year)
Choice 2 - for (Month/Year) through (Month/Year)
Choice 3 - for (Month/Year) on
-
(5)
Choice 1 - ,
Choice 2 - and
Choice 3 - .
-
(6)
Choice 1 - your
Choice 2 - her
Choice 3 - his
NOTE: Fill-ins 3, 4 and 5 repeat as needed.
1602. Situation Where Used:
IC and PE: Student earned income—monthly disregard.
Earned income of a student may be disregarded up to (1) per calendar month but no more than (2) for a calendar year.
Fill-ins:
-
(1)
Choice 1 - $400.00
Choice 2 - Null
-
(2)
Choice 1 - $1,620.00
Choice 2 - Null
1603. Situation Where Used:
IC and PE: Recipient has net loss from self-employment.
The average monthly amount of (1) net loss from self-employment was subtracted from the total of (2) other earned income in figuring (3) income.
Fill-ins:
-
(1)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(2)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(3)
Choice 1 - your
Choice 2 - her
Choice 3 - his
1604. Situation Where Used:
IC and PE: Spouse, parent, or essential person has net loss from self-employment.
The average monthly amount of net loss from self-employment of (1) was subtracted from the total of other income of (2) in figuring (3) income.
Fill-ins:
-
(1)
Choice 1 - your parent
Choice 2 - your parents
Choice 3 - your spouse
Choice 4 - her parent
Choice 5 - her parents
Choice 6 - her spouse
Choice 7 - his parent
Choice 8 - his parents
Choice 9 - his spouse
Choice 10 - (Name of Essential Person)
-
(2)
Choice 1 - your parents
Choice 2 - your spouse
Choice 3 - her parents
Choice 4 - her spouse
Choice 5 - his parents
Choice 6 - his spouse
Choice 7 - (Name of Essential Person)
-
(3)
Choice 1 - your
Choice 2 - her
Choice 3 - his
2230. Situation Where Used:
Change in income. Parents or spouse no longer receives public assistance.
The income of (1) (2) (3) must be considered in figuring (4) because (5) (6) (7) public assistance (8)
Fill-ins:
-
(1)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(2)
Choice 1 - parent
Choice 2 - parents
Choice 3 - spouse
-
(3)
Choice 1 - for (Month/Year)
Choice 2 - for (Month/Year) through (Month/Year)
Choice 3 - for (Month/Year) on
-
(4)
Choice 1 - the amount of your Supplemental Security Income payment
Choice 2 - the amount of her Supplemental Security Income payment
Choice 3 - the amount of his Supplemental Security Income payment
Choice 4 - your eligibility for Supplemental Security Income
Choice 5 - her eligibility for Supplemental Security Income
Choice 6 - his eligibility for Supplemental Security Income
-
(5)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(6)
Choice 1 - parent
Choice 2 - parents
Choice 3 - spouse
-
(7)
Choice 1 - did not receive
Choice 2 - no longer receive
Choice 3 - no longer receives
-
(8)
Choice 1 - for that month
Choice 2 - for those months
Choice 3 - .
2232. Situation Where Used:
Change in income but no change in payment amount.
(1) payment amount remains the same.
Fill-ins:
-
(1)
Choice 1 - Your
Choice 2 - Her
Choice 3 - His
2523. Situation Where Used:
Record has been in suspense due to returned checks and claimant remains ineligible
because of excess income.
Our review of (1) record shows that (2) ineligible (3) (4) for Supplemental Security Income payments because of (5) income.
Fill-ins:
-
(1)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(2)
Choice 1 - you are
Choice 2 - she is
Choice 3 - he is
Choice 4 - you have been
Choice 5 - she has been
Choice 6 - he has been
-
(3)
Choice 1 - beginning
Choice 2 - since
-
-
(5)
Choice 1 - your
Choice 2 - her
Choice 3 - his
3028. Situation Where Used:
The parent-to-child deeming computation changed effective November 1, 1992. However,
the system has not yet begun using the new computation. When the system begins using
it, this paragraph will be included on a one-time notice to recipients affected by
the change.
We use the parents' income to figure the amount of a child's SSI payment. In doing
this, we count only part of the parents' income. Beginning November 1992, we changed
the way we figure how much of the parents' income we count. As a result, in many cases
we count less. This change is the reason (1) due more SSI as shown in the above chart.
Fill-ins:
-
(1)
Choice 1 - you are
Choice 2 - she is
Choice 3 - he is
VA Payments Due to Unusual Medical Expenses
INCM01. Situation Where Used:
We allowed an initial claim but we are still in the process of verifying that VA is
paying for medical expenses. Use on an SSA-L8025-U2, Notice of Award, as the last
paragraph under the caption “Information About Your Payments.”
We may owe (1) more SSI money. We're asking the Department of Veterans Affairs (VA) if some of the
money they paid (2) was for medical expenses. If so, we won't count that money in figuring (3) SSI payments. We'll write to you again to let you know what VA tells us. Until then,
we will count all (4) VA money against (5) SSI payments.
Fill-ins:
-
(1)
Choice 1 - you
Choice 2 - her
Choice 3 - him
-
(2)
Choice 1 - you
Choice 2 - her
Choice 3 - him
-
(3)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(4)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(5)
Choice 1 - your
Choice 2 - her
Choice 3 - his
INCM02. Situation Where Used:
VA verifies that the claimant's VA payment includes money for medical expenses. The
claimant is due an underpayment or an underpayment and an increase in the recurring
payment amount. Use on an SSA-L8100-U2, Notice of Revised Determination or an SSA-L8151-U2,
Notice of Change in Payment (for increase in payment), under the caption, “Why Your Payments Changed.” Use paragraph INCM03 below also.
-
•
We owe (1) more SSI money. The Department of Veterans Affairs (VA) told us that (2) VA payments include money for medical expenses. Because (3) of your VA payment for (4) is for medical expenses, we won't count that money in figuring your SSI payments.
-
•
Later in this letter, we'll tell you how much money we counted against (5) SSI payments for the months we changed.
Fill-ins:
-
(1)
Choice 1 - you
Choice 2 - her
Choice 3 - him
-
(2)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
-
(4)
Choice 1 - (Month/Year)
Choice 2 - (Month/Year through Month/Year)
Choice 3 - (Month/Year) on
-
(5)
Choice 1 - your
Choice 2 - her
Choice 3 - his
INCM03. Situation Where Used:
Same situation as INCM01 above. In addition to using INCM01 paragraphs, use the paragraph
shown below as a fill-in under paragraph 1231 in this section. Use under the caption
“Your Payment is Based on These Facts.”
(1) VA payments of (2) for (3) . We only count (4) for (5) .
Fill-ins:
-
(1)
Choice 1 - Your
Choice 2 - Her
Choice 3 - His
-
-
(3)
Choice 1 - (Month/Year)
Choice 2 - (Month/Year through Month/Year)
Choice 3 - (Month/Year) on
-
-
(5)
Choice 1 - (Month/Year)
Choice 2 - (Month/Year through Month/Year)
Choice 3 - (Month/Year) on
INCM04. Situation Where Used:
We have allowed an initial claim but we are still in the process of verifying that
VA is paying for medical expenses. Subsequently, we receive verification that the
claimant's VA payment does not include money for medical expenses. Use on an SSA-L8166-U2,
Notice of Important Information.
We wrote you earlier that we are asking the Department of Veterans Affairs (VA) for
additional information about (1) payments from them. We needed to find out if (2) VA payments include money for (3) medical expenses.
WHAT VA TOLD US
VA told us that (4) payments don't include additional money for medical expenses. That means we must
count (5) full VA payment of (6) for (7) against your SSI payments. As a result, we have figured your SSI payments correctly.
WHAT YOU SHOULD REMEMBER
If (8) monthly VA payments change to include money for medical expenses, contact us right
away. If this is true, (9) may be due more SSI money.
IF YOU HAVE ANY QUESTIONS
If you have any questions, you can call, write or visit any Social Security office.
If you call or visit our office, please have this letter with you and ask for (10) . The telephone number is shown at the top of this notice.
Fill-ins:
-
(1)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(2)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(3)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(4)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(5)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
-
(7)
Choice 1 - (Month/Year)
Choice 2 - (Month/Year through Month/Year)
Choice 3 - (Month/Year) on
-
(8)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(9)
Choice 1 - you
Choice 2 - she
Choice 3 - he
-
(10)
(Claims representative's name)
INCM05. Situation Where Used:
Use for postentitlement cases under force pay when a change in a monthly VA payment,
which includes money due to medical expenses, results in an increase or decrease in
SSI. Use on an SSA-L8151-U2, Notice of Change in Payment, for an increase or on an
SSA-8155-U2, Notice of Planned Action, for a decrease. Use under the caption “Why Your Payments Changed.” Use paragraph INCM06 below also.
-
•
(1) Department of Veterans Affairs (VA) payment changed from (2) to (3) for (4) . Because (5) of your VA payment for (6) is for medical expenses, we won't count that money in figuring your SSI payments.
-
•
Later in this letter, we'll tell you how much money we counted against (7) SSI payments for the months we changed.
Fill-ins:
-
(1)
Choice 1 - Your
Choice 2 - Her
Choice 3 - His
-
-
-
(4)
Choice 1 - (Month/Year)
Choice 2 - (Month/Year through Month/Year)
Choice 3 - (Month/Year) on
-
-
(6)
Choice 1 - (Month/Year)
Choice 2 - (Month/Year through Month/Year)
Choice 3 - (Month/Year) on
-
(7)
Choice 1 - your
Choice 2 - her
Choice 3 - his
INCM06. Situation Where Used:
Same situation as INCM04 above. In addition to using INCM04 paragraphs, use the paragraph
shown below as a fill-in under paragraph 1231 in this section. Use under the caption
“Your Payment is Based on These Facts.”
(1) VA payments of (2) for (3) . We only count (4) for (5) .
Fill-ins:
-
(1)
Choice 1 - Your
Choice 2 - Her
Choice 3 - His
-
-
(3)
Choice 1 - (Month/Year)
Choice 2 - (Month/Year through Month/Year)
Choice 3 - (Month/Year) on
-
-
(5)
Choice 1 - (Month/Year)
Choice 2 - (Month/Year through Month/Year)
Choice 3 - (Month/Year) on
References:
-
-
•
Notice Requirements for PASS Notices—no notice language, SI 00870.100
-
•
PASS approval or periodic review—need for manual notices SSA-L8166-U2 or SSA-L8155-U2,
SI 00870.070D. SI 00870.080D
-
•
General instructions about manual SSI offset notices—no notice language, SI 02006.010E.6.
-
-
PASS Approval or periodic review— need for manual notices SSA-L8166 or SSA-L8155, SI 00870.070D and SI 00870.080D
Notice language for offset with attorney fee involvement, SI 02006.205B.2.b.
Notice language for offset with attorney involvement—PE situations, SI 02006.215A.3.c.