TN 33 (08-23)
GN 02610.067 Sample Manual Notice of Award When Applying The AR After Title XVI Offset Was Applied
Social Security Administration
Supplemental Security Income
Notice of Award
||Office Address: Street Address
||Telephone Number: 999-9999
||Contact Person: Claims Representative
||Date: December 1, 1992
||Social Security Number: 888-00-8888 DI
||Application Filed: August 1, 1992
This is to notify you that you are eligible to receive Supplemental Security Income
payments under the provisions of Title XVI of the Social Security Act. The rest of
this letter will tell you more about our decision.
|August 1, 1992
||October 31, 1992
|November 1, 1992
Information About Medicaid
Since you are not eligible now for SSI, you are also not eligible for Medicaid based
on SSI. However, if you need help with medical bills, you may still be eligible for
medical assistance. Also, you may be eligible for Medicaid for the months we paid
you SSI. Contact the local Department of Social Services for information about your
State's medical assistance programs and your eligibility for Medicaid. When
you visit that agency, please take this letter with you. It will help the people there answer your questions.
Information About Your Payments
We are sending you a check for $3.00. This is money due you for August 1992 through
Your Payment Is Based On These Facts
You were disabled August 1992 on.
You were living in the State of for August 1992 on.
You have monthly income which must be considered in figuring your payment as follows:
Your Social Security benefits—before deductions for Medicare premiums, if any—of $610.00
for August 1992 on.
Because of your income, you are not eligible to receive SSI payments for November
Information About Your Back Payments
We are sending you an SSI check for $3 in December 1992. We will not count the part
of this money which was due for back payments as your resource for 6 months. If the
money is not spent before July 1, 1993, we will count any money left over as part
of your resources. But things bought with this money may count as resources the month
after they are bought. Your Social Security office can tell you which things count
as resources. You cannot get SSI if the resources we count have a value of more than
Things To Remember
If you think payment may be due you for earlier months or at anytime in the future,
please contact us immediately. If you are not eligible to receive payment during a
month before December 1993, you will have to file a new application to receive payment.
Since we cannot make payments for a month before the month in which an application
is filed, a delay in applying will result in a loss of payment for any months in which
you are otherwise eligible.
Do You Disagree With The Decision?
If you disagree with this decision, you have the right to appeal. A person who did
not make the first decision will decide your case. We will review those parts of the
decision with which you disagree and will look at any new facts you have. We may also
review those parts with which you agree and may make them unfavorable or less favorable
You have 60 days to ask for an appeal.
The 60 days start the day after you receive this letter.
You must have a good reason if you wait more than 60 days.
To appeal, you must fill out a form called "Request for Reconsideration." The form
number is SSA-561. To get this form, contact one of our offices. We will help you
fill out the form.
How To Appeal
There are two ways to appeal. You can pick the one you want. If you meet with us in
person, it may help us decide your case.
Case Review. You have the right to review the facts in your file. You can give us more facts
to add to your file. Then we will decide your case again. You will not meet with the
person who decides your case. This is the only kind of appeal you can have to appeal
a medical decision.
Informal Conference. You will meet with the person who decides your case. You can tell that person why
you think you are right. You can give us more facts to help prove you are right. You
can bring other people to help explain your case.
If You Want Help With Your Appeal
You can have a friend, lawyer or someone else help you. There are groups that can
help you find a lawyer or give you free legal services if you qualify. There are also
lawyers who do not charge unless you win your appeal. We have a list of groups that
can help you with your appeal.
If you get someone to help you, you should let us know. If you hire someone, we must
approve the fee before they can collect it.
If You Have Any Questions
If you have any questions, you may call, write, or visit any Social Security office.
If you call or visit our office, please have this letter with you and ask for . The telephone number is .
Also, if you plan to visit an office, you may call ahead to make an appointment. This
will help us serve you more quickly when you arrive at the office.
Name of Manager