Effective Dates: 08/28/2023 - Present Previous | Next

TN 7 (08-23)

NL 00802.025 Completion of the Manual SSA-L8030-U2, Notice of Disapproved Claim

A. Introduction

The SSA-L8030-U2 is a manual form with preprinted appeal rights. Select captions and paragraphs from those shown below to produce a complete notice. The SSA-L8030 is also on the DOCS for completing notices on the personal computer. It directs the user to select appropriate paragraphs and fill-ins to complete the notice.

B. Procedure

NL 00802.001B through NL 00802.001C explain how to use the charts below for completing notices and the procedure for preparing a manual notice.

1. Chart for Completion of the SSA-L8030-U2

The following chart provides a list of the captions and paragraphs you must consider when preparing the body of the SSA-L8030-U2.

  1. a. 

    WHY WE CAN'T PAY YOU (Caption 1903) (Mandatory)

NL Reference Paragraph Use
NL 00804.215 1500

1503 		N12 — Use both paragraphs if the claimant has withdrawn the application.
​ ​ The paragraphs for nonmedical denials follow:
NL 00804.175 1239 N01 — Excess income.
NL 00804.180 1293 N04—The claimant has excess resources. (Use with 1294—see b. below.)
NL 00804.165 1200 N02 — Resident of a public institution. (Use this paragraph if INTM50 and INTM51 below do not apply.)
NL 00804.170 2220 N13 — Not a U.S. citizen or eligible alien.
​ 1216 N03—Not residing in U.S.
NL 00804.140 1116

1118 		N14 — Claimant has not attained age 65. Choose appropriate paragraph.
NL 00804.135 1110 N18 — Did not produce requested information.
​ 1105 N17—Failure to pursue claim.
NL 00804.130 1081 N06 — Failure to file for other benefits.
NL 00804.115 1392 An individual can qualify for SSI on the basis of disability or blindness.
NL 00804.200 1407 Claimant disabled but ineligible for SSI for other reasons.
​ 1384

1390

SGAM51 		Claimant performing substantial gainful activity (SGA). Choose appropriate paragraph.
  1. b. 

    HOW YOU MAY BE ABLE TO RECEIVE SSI (Caption 1929) (Use only when you use paragraph 1293 above.)

NL Reference Paragraph Use
NL 00804.180 1294 Provides information about a conditional payment agreement.
  1. c. 

    OUR DECISION IS BASED ON THESE FACTS (Caption 1906) (Mandatory caption for excess income, N01 denials.)

NL Reference Paragraph Use
NL 00804.145 1130 Individual is eligible in more than one category or, if a child, age is given.
​ 1131 Claimant filing as member of a couple. Spouse is eligible.
NL 00804.150 1145 Individual was both a student and non-student for the period of time covered on the record.
NL 00804.160 1161 Spouse is eligible for part of initial period of eligibility.
​ 1183 Couple not living together.
NL 00804.155 1165 Use if the claimant is a child living in the household of the parent(s) or the federal living arrangement code is “D”.
NL 00804.190 1315 Tells claimant's county and/or State of residence. (Mandatory)
​ 1163 Tells claimant's State living arrangement. (Mandatory for States that pay an optional State supplement.)
​ 1169 State involvement.
​ 1168 State living arrangement.
NL 00804.170 1001

1003 		Use both paragraphs if sponsor-to-alien deeming applies.
NL 00804.175 1231

1616

2233 		Lead-in paragraphs to introduce income. Choose appropriate paragraph.
​ 1280

1281

1282 		Windfall offset applies — Choose the appropriate paragraph.
​ 1232 Describes type, period and amount of income.
​ 1248 Income of spouse or parent(s) deemed to claimant.
​ 1258 The value of the one-third reduction (VTR) applies.
​ 1260 Claimant receives in-kind support and maintenance.
​ 1253 Claimant received a one-time payment of unearned income.
​ 1254 Spouse or parent(s) received a one- time payment of unearned income.
​ 1244

1245

1257

1601 		Choose any applicable paragraphs to address what is not income or what is disregarded from income.
​ 1602

1603

1604 		​
  1. d. 

    ABOUT YOUR OVERPAYMENT (Caption 1909) (Use only if the claimant received an overpayment because of incorrect payments we made while we were still working on the claim.)

NL Reference Paragraph Use
NL 00804.205 1042 Claimant received PD/PB payments and is ineligible because not disabled and overpaid for reasons other than disability/blindness.
NL 00804.210 1437 Request for refund of overpayment.
​ 1439 Claimant received SSI payments while we worked on claim and is ineligible.
  1. e. 

    IF YOU THINK YOU SHOULDN'T HAVE TO PAY US BACK (Caption 1911) (Use only if you have used the preceding caption.)

NL Reference Paragraph Use
NL 00804.210 1434 (Mandatory paragraph for this caption.) Provides claimant with waiver information.
  1. f. 

    INFORMATION ABOUT MEDICAID AND OTHER BENEFITS (Caption 1915) (Mandatory) (Use “AND OTHER BENEFITS” as part of the caption when paragraph 1311 below is used.)

NL Reference Paragraph Use
NL 00804.190 1311 State administers its own supplementation program.
NL 00804.110 1150

1151

1155

1170 		Choose the appropriate Medicaid referral paragraph for the claimant's State of residence.
  1. g. 

    THINGS TO REMEMBER (Caption 1926) (Mandatory)

NL Reference Paragraph Use
NL 00804.240 1481 Advises the claimant to refile if they believe they can qualify for SSI. (Mandatoryparagraph for this caption.)
​ 1487 Title II decision will be in a separate notice.
​ 1000 The other notice with this one is in English/Spanish.
NL 00804.245 1598 No title II (or additional title II) benefits are payable.
NL 00804.190 1310 Claimant not eligible for optional State supplement.
NL 00804.195 1345 Information about category of eligibility claimant filed under or that we did not develop age, disability or blindness.
NL 00804.220 2834 Value of the one-third reduction (VTR) may not apply if claimant begins to pay pro-rata share of expenses.
NL 00804.150 1456 Child is age 18 and does not regularly attend school or student child over the age of 18 but under age 22 stops attending school regularly.
NL 00804.210 1438 Claimant may be overpaid.
NL 00804.160 1181 Spouse also filed for SSI and will receive a separate notice.
NL 00804.185 2489 Representative payee will receive a copy of notice.
  1. h. 

    DO YOU DISAGREE WITH THE DECISION?/HOW TO APPEAL/IF YOU WANT HELP WITH YOUR APPEAL/NEW APPLICATION (Paragraph 1728) (Mandatory)

Appeal rights are preprinted as part of the SSA-L8030-U2 and also appear on the FONS version of the notice.

  1. i.  

    IF YOU HAVE ANY QUESTIONS (Unnumbered) (Mandatory)

NL Reference Paragraph ​
NL 00804.240 MISM53 Closing paragraph (Mandatory)
​ ​ This caption and the paragraphs under it are not preprinted on the SSA-L8030-U2 so it is important that you add them to the notice. However, they do appear as part of this notice on the FONS version.

2. Signature

Close the notice as follows:

Name of Manager,

Title

3. Enclosures

Two lines under “Title,” at the left margin, type “Enclosure(s)” and list the enclosures, starting a new line for each one.

4. Notice Copies

Two lines under the list of enclosures, at the left margin, type “cc:” if you are sending a copy of the notice to a representative payee, authorized representative and/or legal guardian. List the name(s) of the individual(s) to whom you are sending a copy and under each name list the city and State of the individual's address.

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900802025
NL 00802.025 - Completion of the Manual SSA-L8030-U2, Notice of Disapproved Claim - 08/28/2023
Batch run: 08/28/2023
Rev:08/28/2023