TN 15 (02-90)

NL 00804.215 Withdrawal and Voluntary Termination

 

  1. Situation Where Used:

Withdrawal prior to adjudication. (Used with paragraph 1503.)

 

We have approved    (1)    request for withdrawal of    (2)    application for Supplemental Security Income payments. Therefore, we have not determined whether or not    (3)    eligible to receive Supplemental Security Income payments.

 

  1. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  2. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  3. Choice 1 - you are

    Choice 2 - she is

    Choice 3 - he is

     

  1. Situation Where Used:

IC: Withdrawal prior to adjudication. (Used with paragraph 1500.)

PE: Request for termination of eligibility approved. (Used with paragraph 2470.)

 

If    (1)    Supplemental Security Income,    (2)    should tell us no later than 60 days after the date of this notice. If     (3)    mind after that please contact us immediately to file a new application since, after that time, we will not be able to make payment for any month before the month in which    (4)    .

 

  1. Choice 1 - you change your mind and decide you want

    Choice 2 - she changes her mind and decides she wants

    Choice 3 - he changes his mind and decides he wants

     

  2. Choice 1 - you

    Choice 2 - she

    Choice 3 - he

     

  3. Choice 1 - you change your

    Choice 2 - she changes her

    Choice 3 - he changes his

     

  4. Choice 1 - you apply

    Choice 2 - she applies

    Choice 3 - he applies

     

  1. Situation Where Used:

Individual residing in State for which Social Security Administration administers optional supplementation program. Individual waives State supplement.

 

Based on your request, we will no longer send    (1)    money from the    (2)    beginning    (3)    . If    (4)    to receive this money, you should contact any Social Security office.

 

  1. Choice 1 - you

    Choice 2 - her

    Choice 3 - him

     

  2. Choice 1 - State of (State Name)

    Choice 2 - District of Columbia

     

  3. (Month/Year)

     

  4. Choice 1 - you later decide you wish

    Choice 2 - she later decides she wishes

    Choice 3 - he later decides he wishes

     

  1. Situation Where Used:

Recipient's request for termination of eligibility approved. (Used with paragraph 1503.)

 

Based on your request, we    (1)          (2)    eligibility for Supplemental Security Income payments beginning    (3)    .    (4)   

 

  1. Choice 1 - have terminated

    Choice 2 - will terminate

     

  2. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  3. (Month/Year)

     

  4. Choice 1 - We will no longer send you checks.

    Choice 2 - We will no longer send her checks.

    Choice 3 - We will no longer send him checks.

    Choice 4 - Null

     

  1. Situation Where Used:

Recipient requests termination of eligibility effective for a month for which he/she received payment and such payment was not returned.

 

You asked that    (1)    eligibility for Supplemental Security Income be terminated beginning    (2)    . We cannot terminate    (3)    eligibility that month unless you pay back the     (4)    we sent    (5)          (6)    . If you repay this money, we will terminate    (7)    eligibility back to     (8)    . To repay the money, please mail a check or money order for this amount made payable to the Social Security Administration,    (9)    , to    (10)    Social Security office. You should also return to    (11)    Social Security office any Supplemental Security Income checks    (12)    after receiving this notice.

 

  1. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  2. (Month/Year)

     

  3. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  4. $$$.¢¢

     

  5. Choice 1 - you

    Choice 2 - her

    Choice 3 - him

     

  6. Choice 1 - for (Month/Year)

    Choice 2 - for (Month/Year) through (Month/Year)

     

  7. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  8. (Month/Year)

     

  9. (Recipient's Social Security Number)

     

  10. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  11. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  12. Choice 1 - you get

    Choice 2 - she gets

    Choice 3 - he gets

     

  1. Situation Where Used:

Recipient decides (within the 60 day grace period) not to terminate eligibility.

 

Because you changed your mind and do not want to    (1)    for Supplemental Security Income,    (2)          (3)          (4)    .

 

  1. Choice 1 - terminate your eligibility

    Choice 2 - terminate her eligibility

    Choice 3 - terminate his eligibility

    Choice 4 - withdraw your application

    Choice 5 - withdraw her application

    Choice 6 - withdraw his application

     

  2. Choice 1 - we will begin sending your payments right away. You will also receive any payments you returned

    Choice 2 - we will begin sending her payments right away. You will also receive any payments that were returned

    Choice 3 - we will begin sending his payments right away. You will also receive any payments that were returned

    Choice 4 - we can pay you

    Choice 5 - we can pay her

    Choice 6 - we can pay him

    Choice 7 - we have reviewed your claim. Based on the information available to us, we find that you are not eligible for payment at this time.

    Choice 8 - we have reviewed her claim. Based on the information available to us, we find that she is not eligible for payment at this time.

    Choice 9 - we have reviewed his claim. Based on the information available to us, we find that he is not eligible for payment at this time.

     

  3. Choice 1 - for (Month/Year)

    Choice 2 - for (Month/Year) through (Month/Year)

    Choice 3 - for (Month/Year) on

    Choice 4 - Null

     

  4. Choice 1 - ,

    Choice 2 - and

    Choice 3 - .

    Choice 4 - Null

     

  1. Situation Where Used:

Recipient requested withdrawal of application and refunded all payments received or total payments can be withheld from future title II benefits, or no payments were made.

 

You asked that    (1)    application for Supplemental Security Income be withdrawn.    (2)    we have approved    (3)    request.    (4)   

 

  1. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  2. Choice 1 - Since you paid back the money we sent you,

    Choice 2 - Since you paid back the money we sent her,

    Choice 3 - Since you paid back the money we sent him,

    Choice 4 - Since you asked us to withhold from your Social Security benefits an amount to repay the Supplemental Security Income payment we sent you,

    Choice 5 - Since you asked us to withhold from your Social Security benefits an amount to repay the Supplemental Security Income payment we sent her,

    Choice 6 - Since you asked us to withhold from your Social Security benefits an amount to repay the Supplemental Security Income payment we sent him,

    Choice 7 - Null

     

  3. Choice 1 - your

    Choice 2 - the

     

  4. Choice 1 - No more checks will be sent to you.

    Choice 2 - No more checks will be sent to her.

    Choice 3 - No more checks will be sent to him.

    Choice 4 - Null

     

Manual Paragraphs

Withdrawal and Voluntary Termination

 

WDWM50.  Situation Where Used:

Withdrawal requested after payment—refund requested.

 

   (1)    asked us to withdraw    (2)    application for Supplemental Security Income checks. We cannot do this until    (3)    back the    (4)    we have already sent to    (5)    .    (6)    must also return to    (7)    Social Security office any Supplemental Security Income checks    (8)    from now on. As soon as    (9)    this money,    (10)    application will be withdrawn. If    (11)    done so already, please mail a check or money order to    (12)    Social Security office. Make it payable to the Social Security Administration. Do not mail cash to the Social Security office.

 

  1. Choice 1 - You have

    Choice 2 - (Name of Claimant) has

     

  2. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  3. Choice 1 - you pay

    Choice 2 - she pays

    Choice 3 - he pays

     

  4. $$$.¢¢

     

  5. Choice 1 - you

    Choice 2 - her

    Choice 3 - him

     

  6. Choice 1 - You

    Choice 2 - She

    Choice 3 - He

     

  7. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  8. Choice 1 - you get

    Choice 2 - she gets

    Choice 3 - he gets

     

  9. Choice 1 - you repay

    Choice 2 - she repays

    Choice 3 - he repays

     

  10. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  11. Choice 1 - you have not

    Choice 2 - she has not

    Choice 3 - he has not

     

  12. Choice 1 - your

    Choice 2 - her

    Choice 3 - his


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900804215
NL 00804.215 - Withdrawal and Voluntary Termination - 03/26/1999
Batch run: 01/27/2009
Rev:03/26/1999