Effective Dates: 08/05/2020 - Present Previous | Next

TN 16 (08-20)

SI 02003.040 Manual Preparation of the SSA-L8125-F6, Notice to the State for Exception and Proration Cases

Complete the following pages of the SSA-L8125-F6 for IAR exception and proration cases:

  • •

    A. Page 1 - State Agency Identifying Information

  • •

    B. Page 3 – Claimant Information

  • •

    C. Page 4 - 6 – Retroactive Amount Due Summary

A. Page 1 State Agency Identifying Information

Item

Action

TO:

Enter the name and address of the State agency receiving the IAR check.

DATE:

Enter the date the notice is prepared.

CLAIM NUMBER:

Enter the social security number (SSN).

GR CODE:

Enter the State and county code of the State agency receiving the IAR check - the same date posted to the SSR.

IAR PAYMENT PENDING CASE:

Enter the complete address of the servicing FO.

B. Page 3 Claimant Information

Item

Action

Initial Claim

Check if applicable.

Post-Eligibility Claim

Check if applicable.

Other

Check only if future instructions require it.

Recipient's Name

Enter the recipient's name.

SSN

Enter the recipient's SSN.

Representative Payee Name

Enter the payee's name if applicable.

Date of SSI Eligibility

Enter the date (MM/DD/YY) of SSI eligibility in both IC or PE claims.

NOTE: Also enter deceased (MM/DD/YY) if the recipient dies before payment is made. Leave blank if IC/PE denied.

Amount of SSI Retroactive Benefits Due

Enter the amount of SSI retroactive benefits due being sent to the State. If no underpayment due enter "0".

Amount and Month of Recurring SSI Payment

Enter the amount and month of recurring SSI payment. Enter "0" if no recurring payment due.

Under the block labeled (TO: Social Security Administration Address) Record the servicing FO address.

1. State's Account of Reimbursement Claimed

Item

Action

Date Returned to SSA

Enter date servicing FO received SSA-L8125-F6 from the State.

GR Code

Enter the GR Code.

NOTE: State completes all other items in this section.

2. To be completed by SSA

Item

Action

SSA Telephone #

Enter the SSAFO telephone number.

Amount of reimbursement check(s) released to the State

Enter amounts.

Date

Enter the date the last IAR check was released to the State.

BY

Enter the name of the FO worker completing the SSA-L8125-F6. Enter no check due if claim denied or no IAR due.

C. Pages 4, 5, and 6 of the retroactive amount due summary

Enter the months covered by the retroactive check and the dollar amounts per month equal to the retroactive check. When the amount for consecutive months are equal, show the beginning date of the first consecutive month (MM/DD/YY) and the ending date of the last consecutive month (MM/DD/YY) plus the per month dollar amount ($000).

Enter any prorated dates for a PE case on a separate line.

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0502003040
SI 02003.040 - Manual Preparation of the SSA-L8125-F6, Notice to the State for Exception and Proration Cases - 08/05/2020
Batch run: 08/05/2020
Rev:08/05/2020