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 Number Form Highlighted Paragraph Situation

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900804700
NL 00804.700 - List of Sample SSI Notices - 03/26/1999
Batch run: 06/16/2017
Rev:03/26/1999