TN 25 (02-95)

NL 00804.700 List of Sample SSI Notices

This section contains examples of notices for specific situations. In some samples, specific language is highlighted to show how it may be used in a notice. However, since there are many variables in SSI notices, e.g., representative payees, eligibility factors, etc., do not send the notices represented here to the public. Instead, use NL 00802 and
NL 00803 for additional paragraphs tailored to the specific situation for which you are sending the notice.

Notice NumberFormHighlighted ParagraphSituation

1

SSA-L8155-U2

SUSM50
SUSM51
SUSM52

We are suspending the following month's benefit by imputing N20 (failure to cooperate) during the Goldberg/Kelly temporary period.
(See SI 02301.235G.2.)

NOTE: We do not use the payment chart (paragraph 2016) when the only change the notice addresses is N20 for the current computation month (CCM).

2

SSA-L8166-U2

PENM50
PENM52

Penalty Notice—We are withholding a penalty ($25) for the first time.
(See SI 02301.110E.1.)

3

SSA-L8151-U2

PMTM01

N05 Unconfirmed Eligibility—Use of N05 for past nonpay months in reinstatement case.
(See SI 02301.220C.)

4

SSA-L8165-U2

GBKM06
GBKM08

Correcting Multiple Payments (including payments over the payment ceiling.
(See SI 02301.315G, Example 1.)

5

SSA-L8165-U2

GBKM07
GBKM08

Correcting Payments Over the Payment Ceiling
(See SI 02301.315G, Example 2.)

6

SSA-L8151-U2

COLM50

Correct Increased PPL During an
Appeal—COLA increase
(See SI 02301.325D.)

7

SSA-L8155-U2

COLM50

Correct Reduced PPL During an
Appeal—COLA decrease
(See SI 02301.325D.)

Sample Notice #1 - SSA-L8155-U2, Notice of Planned Action

G-NL 00804.700-1

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Sample Notice #1 - SSA-L8155-U2, Notice of Planned Action

G-NL 00804.700-2

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Sample Notice #1 - SSA-L8155-U2, Notice of Planned Action

G-NL 00804.700-3

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Sample Notice #2 - SSA-L8166-U2, Notice of Important Information

G-NL 00804.700-4

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Sample Notice #2 - SSA-L8166-U2, Notice of Important Information

G-NL 00804.700-5

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Sample Notice #2 - SSA-L8166-U2, Notice of Important Information

G-NL 00804.700-6

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Sample Notice #3 - SSA-L8151-U2, Notice of Change in Payment

G-NL 00804.700-7

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Sample Notice #3 - SSA-L8151-U2, Notice of Change in Payment

G-NL 00804.700-8

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Sample Notice #3 - SSA-L8151-U2, Notice of Change in Payment

G-NL 00804.700-9

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Sample Notice #4 - SSA-L8165-U2, Notice of Important Information

G-NL 00804.700-10

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Sample Notice #4 - SSA-L8165-U2, Notice of Important Information

G-NL 00804.700-11

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Sample Notice #4 - SSA-L8165-U2, Notice of Important Information

G-NL 00804.700-12

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Sample Notice #4 - SSA-L8165-U2, Notice of Important Information

G-NL 00804.700-13

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Sample Notice #5 - SSA-L8165-U2, Notice of Important Information

G-NL 00804.700-14

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Sample Notice #5 - SSA-L8165-U2, Notice of Important Information

G-NL 00804.700-15

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Sample Notice #5 - SSA-L8165-U2, Notice of Important Information

G-NL 00804.700-16

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Sample Notice #6 - SSA-L8151-U2, Notice of Change in Payment

G-NL 00804.700-17

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Sample Notice #6 - SSA-L8151-U2, Notice of Change in Payment

G-NL 00804.700-18

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Sample Notice #7 - SSA-L8155-U2, Notice of Planned Action

G-NL 00804.700-19

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Sample Notice #7 - SSA-L8155-U2, Notice of Planned Action

G-NL 00804.700-20

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Sample Notice #7 - SSA-L8155-U2, Notice of Planned Action

G-NL 00804.700-21

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To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900804700
NL 00804.700 - List of Sample SSI Notices - 11/20/2006
Batch run: 01/27/2009
Rev:11/20/2006