NL: Notices, Letters and Paragraphs
TN 3 (02-97)
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.
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N12 — Use both paragraphs if the claimant has withdrawn the application.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. |
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. |
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 |
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. |
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. |
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. |
THINGS TO REMEMBER (Caption 1926) (Mandatory)
| NL Reference | Paragraph | Use |
|---|---|---|
| NL 00804.240 | 1481 | Advises the claimant to refile if he/she believes he/she 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. |
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.
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.