Supplemental Security Income 
         Notice of Revised Determination 
          
                               Date: May 15, 1991
         Name
         Address                 Social Security Number: XXX-XX-XXXX
         City, State ZIP Code
          
         We are writing to tell you about a change in your Supplemental Security Income (SSI)
            payment. The following chart shows the SSI money due you for the month we changed.
            As you can see from the chart, we are only changing your payments for one month in
            the past. The rest of this letter will tell you more about this change.
         
          
         Your Payment Is Changed as Follows: 
         
            
               
                  
                  
                  
               
               
                  
                  
                     
                     | From | Through | Amount Due Each Month | 
               
               
                  
                  
                     
                     | April 01, 1991 | April 30, 1991 | $.00 | 
               
            
          
          
         Your Payment is Based on These Facts: 
         If you receive money, gifts, insurance or other payments because of a death, we will
            not count what you received against your SSI payments as long as it is spent on expenses
            related to the last illness or burial.
         
         
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                     You received $2,500.00 in life insurance on Charles Davidson in April 1991. 
 
 
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                     You spent $2,000.00 on expenses related to his last illness or burial. 
 
 
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                     We must use the amount you did not spend on his last illness or burial expenses in
                        figuring your SSI payments. We are using $500 of the money you received in April 1991
                        to figure your payment for April 1991.
                          
 
 
TURN THIS OVER IF YOU THINK WE ARE WRONG 
         YOUR RIGHT TO APPEAL 
          
         Do You Think We're Wrong? 
         If you think we're wrong, you have the right to appeal. A person who hasn't seen your
            case will look at it. That person will be an Administrative Law Judge. In the rest
            of our letter we'll call this person an ALJ. The ALJ will correct mistakes and look
            at any new facts you have before deciding your case. We call this a hearing.
         
         
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                     You have 60 days to ask for a hearing. The 60 days start the day after you get this letter. You'll have to have a good reason for waiting more than 60 days to ask for a hearing. You have to ask for an appeal in writing. We'll ask you to sign an SSA form HA-501,
                        called “Request for Hearing.” Contact one of our offices if you want help.
                        
 
 
How A Hearing Works 
         A hearing works like this.
         
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                     The ALJ will tell you the time and place for the hearing. The ALJ will explain the law in your case. The ALJ will state the known facts and
                        tell you what has to be decided.
                      You can tell the ALJ why you think we're wrong. You can give the ALJ more facts. And
                        you can bring people to say why you're right.
                      The ALJ can make people come to your hearing and bring important papers. You can question
                        these people at your hearing.
                      We'll ask if you want to go to the hearing in person. If you say you want to go, you
                        should attend if at all possible. If you change your mind or if you can't get to the
                        hearing, you should tell us. You should know that your being there may help the ALJ
                        decide your case.
                        
 
 
If You Want Help With Your Hearing 
         You may want help from a friend, lawyer or someone else. There are groups that can
            find you a lawyer. Some can give you a free lawyer. We can give you the names of these
            groups.
         
                                  XXX-XX-XXXX
         04/15/88                       Page 2
          
         Things to Remember 
         
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                     This decision refers only to your claim for Supplemental Security Income payments. 
 
 
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                     This determination replaces all previous determinations for the above period. 
 
 
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                  • 
                     We may be in touch with you later about any payments we previously made.   
 
 
If You Have Any Questions 
         If you have any questions, you may call us at (111) 222-3333. We can answer most questions
            over the phone. You may also write or visit any Social Security office. The office
            that serves your area is located at:
         
         Street Address
 City/State/ZIP Code
         
         If you do call or visit an office, please have this letter with you. It will help
            us answer your questions. 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.
         
          
          
          
                                   Manager's Name
                                   Title