Supplemental Security Income
Social Security Number:
On __________, we talked with ________________about your eligibility for Supplemental
Security Income (SSI). Based on that talk, we made an informal decision that you are
not eligible for SSI. This informal decision is only about your eligibility for SSI.
This decision is not about eligibility for Social Security benefits or Medicare.
Why You Are Not Eligible
We believe you are not eligible for SSI for the reason(s) checked below.
[ ] _____________________ told us that you do not want to file a claim for SSI.
[_] You are not age 65 and are not blind or disabled.
[_] You are not a U.S. citizen, national, or eligible alien.
[_] You are not a resident of the U.S. for SSI purposes. You must be a resident of
one of the States, the District of Columbia, or the Northern Mariana Islands to receive
[_] You (or you and your spouse) have monthly income of about $ _________. This is
too high for SSI payments in your State. (See the enclosure for important information.)
[_] You (or you and your spouse) own resources worth about $ __________. This is more
than the SSI limit of $_________. (See the enclosure for important information.)
(See Next Page)
Form SSA-L991-U3 (8-97)
Destroy Prior Editions
Page 2 of 2
Why You May Want To File A Claim
You may want to file a claim for SSI if:
you want a formal decision about your eligibility, or
you disagree with our informal decision, or
you want to give us more information about your case.
If you decide to file, you should do so right away. The sooner we get your signed
application, the sooner we can decide if you are eligible. If we decide you are eligible,
you could lose benefits if we receive your signed application after__________________.
If You Have Any Questions
If you have any questions, you should 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 and address are shown at the top of this letter. We can answer
most questions over the phone.
Also, if you plan to visit an office, you may call ahead to make an appointment. This
will help us serve you better.
Form SSA-L991-U3 (8-97)
INFORMATION THAT MAY HELP YOU GET SSI
You may be eligible for SSI if one or more of the following situations apply to you.
If you think any apply, contact your local Social Security office as soon as possible
to file an application for SSI.
You Can Set Up A Plan For Achieving Self-Support (PASS)
A PASS can help you reach a work goal. It lets you set aside money and/or things you
own to pay for things you need to reach the goal. For example, you could set aside
money to start a business, go to school or get training for a job.
Any person who receives SSI because of a disability or blindness may have a PASS.
In addition, a person who has a disability or is blind and does not receive SSI because
his or her income or resources are too high may use an approved plan to become, eligible
Money that is saved under a PASS will not count against your resource limit of $2,000
($3,000 for a couple) while the plan is in effect.
You can write a plan or we can help you find someone to write one. But we must approve
the plan before you can use it.
You Can Set Up A Burial Fund
You (and your spouse) can set aside up to $1,500 each to pay for burial expenses.
In most cases this money will not count as a resource for SSI.
If you (and your spouse) own life insurance policies or have other burial arrangements
in addition to your $1,500 burial funds, some of the money in the burial fund may
count toward the resource limit of $2,000 for an individual or $3,000 for a couple.
Interest earned on your burial fund that is left in the fund does not count as a resource
You May Get SSI While Trying to Sell Excess Resources
You may be able to receive SSI for some months if you:
Sign an agreement which allows you to receive SSI while you are trying to sell the
property that causes your resources to be over the limit, and
You agree to repay any SSI you receive while trying to sell the property.
If Your Income or Resources Change
You may become eligible for SSI if your income or resources change. Contact us again
if this happens.