TN 23 (04-94)

1231.  Situation Where Used:

IC: Award—chargeable income to be counted.

PE: Change in income.

   (1)          (2)    monthly income which must be considered in figuring    (3)    payment as follows—

Fill-ins:

1. Choice 1 - You

   Choice 2 - She

   Choice 3 - He

    

2. Choice 1 - have

   Choice 2 - has

   Choice 3 - had

    

3. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

1232.  Situation Where Used:

IC: Specific type, amount, and period of countable income.

PE: Change in income.

   (1)          (2)    of    (3)           (4)          (5)   

Fill-ins:

1. Choice 1 - Your

   Choice 2 - Her

   Choice 3 - His

   Choice 4 - The

    

2. Choice 1 - wages

   Choice 2 - Social Security benefits—before deductions for Medicare Medical insurance premiums,

   Choice 3 - railroad retirement benefits—before deductions for Medicare premiums, if any

   Choice 4 - black lung benefits

   Choice 5 - Veterans Administration compensation

   Choice 6 - workmen's compensation

   Choice 7 - Veterans Administration pension

   Choice 8 - employment related pension

   Choice 9 - assistance payments based on need

   Choice 10 - rents, interest, dividends, or royalties

   Choice 11 - civil service pension

   Choice 12 - other unearned income

   Choice 13 - support payments from parent

   Choice 14 - military pension

   Choice 15 - net income from self-employment

   Choice 16 - net loss from self-employment

   Choice 17 - income of your sponsor

   Choice 18 - income of her sponsor

   Choice 19 - income of his sponsor

   Choice 20 - income of your sponsor and the spouse of your sponsor

   Choice 21 - income of her sponsor and the spouse of her sponsor

   Choice 22 - income of his sponsor and the spouse of his sponsor

   Choice 23 - Social Security benefits—before deductions for Medicare premiums, if any—

   Choice 24 - railroad retirement benefits—before any deductions for Medicare premiums—

    

3. $$$.¢¢

    

4. Choice 1 - for (Month/Year)

   Choice 2 - for (Month/Year) through (Month/Year)

   Choice 3 - for (Month/Year) on

   Choice 4 - or less for (Month/Year)

   Choice 5 - or less for (Month/Year) through (Month/Year)

   Choice 6 - or less for (Month/Year) on

    

5. Choice 1 - ,

   Choice 2 - and

   Choice 3 - .

NOTE: Repeat fill-ins as needed.

1234.  Situation Where Used:

IC: Individual has deemed countable income.

PE: Change in income.

The income of    (1)          (2)    which is counted as    (3)    income of    (4)          (5)          (6)   

Fill-ins:

1. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

2. Choice 1 - spouse

   Choice 2 - parent

   Choice 3 - parents

   Choice 4 - sponsor

   Choice 5 - sponsor and the spouse of your sponsor

   Choice 6 - sponsor and the spouse of her sponsor

   Choice 7 - sponsor and the spouse of his sponsor

    

3. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

4. $$$.¢¢

    

5. Choice 1 - for (Month/Year)

   Choice 2 - for (Month/Year) through (Month/Year)

   Choice 3 - for (Month/Year) on

    

6. Choice 1 - ,

   Choice 2 - and

   Choice 3 - .

NOTE: Fill-ins 2-6 repeat as needed.

1235.  Situation Where Used:

IC: Individual receives support and maintenance.

PE: Change in income.

NOTE: OBSOLETE—(Replaced by 1260, July 15, 1986.)

Support and maintenance    (1)    received which we value at     (2)          (3)          (4)   

Fill-ins:

1. Choice 1 - you

   Choice 2 - she

   Choice 3 - he

   Choice 4 - your spouse

   Choice 5 - her spouse

   Choice 6 - his spouse

    

2. $$$.¢¢

    

3. Choice 1 - for (Month/Year)

   Choice 2 - for (Month/Year) through (Month/Year)

   Choice 3 - for (Month/Year) on

    

4. Choice 1 - ,

   Choice 2 - and

   Choice 3 - .

NOTE: Fill-ins 2-4 repeat as needed.

1239.  Situation Where Used:

IC: Denial for excess income.

PE: Suspension due to excess income.

Because of    (1)    income,    (2)    not eligible to receive Supplemental Security Income payments    (3)           (4)   

Fill-ins:

1. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

2. Choice 1 - you are

   Choice 2 - you were

   Choice 3 - she is

   Choice 4 - she was

   Choice 5 - he is

   Choice 6 - he was

    

3. Choice 1 - for (Month/Year)

   Choice 2 - for (Month/Year) through (Month/Year)

   Choice 3 - for (Month/Year) on

    

4. Choice 1 - ,

   Choice 2 - and

   Choice 3 - .

NOTE: Fill-ins 3 and 4 repeat as needed.

1240.  Situation Where Used:

Award—no countable income.

PE: For 1 or more months covered and there is no income on the record.

   (1)          (2)    no income    (3)          (4)   

Fill-ins:

1. Choice 1 - You

   Choice 2 - You and your parent

   Choice 3 - You and your parents

   Choice 4 - You and your spouse

   Choice 5 - Your parent

   Choice 6 - Your parents

   Choice 7 - Your spouse

   Choice 8 - She

   Choice 9 - She and her parent

   Choice 10 - She and her parents

   Choice 11 - She and her spouse

   Choice 12 - Her parent

   Choice 13 - Her parents

   Choice 14 - Her spouse

   Choice 15 - He

   Choice 16 - He and his parent

   Choice 17 - He and his parents

   Choice 18 - He and his spouse

   Choice 19 - His parent

   Choice 20 - His parents

   Choice 21 - His spouse

   Choice 22 - Your sponsor

   Choice 23 - Your sponsor and the spouse of your sponsor

   Choice 24 - You, your sponsor, and the spouse of your sponsor

   Choice 25 - Her sponsor

   Choice 26 - Her sponsor and the spouse of her sponsor

   Choice 27 - She, her spouse, and the spouse of her sponsor

   Choice 28 - His sponsor

   Choice 29 - His sponsor and the spouse of his sponsor

   Choice 30 - He, his sponsor, and the spouse of his sponsor

   Choice 31 - You and your sponsor

   Choice 32 - She and her sponsor

   Choice 33 - He and his sponsor

    

2. Choice 1 - have

   Choice 2 - has

   Choice 3 - had

    

3. Choice 1 - for (Month/Year)

   Choice 2 - for (Month/Year) through (Month/Year)

   Choice 3 - for (Month/Year) on

    

4. Choice 1 - ,

   Choice 2 - and

   Choice 3 - .

NOTE: Repeat fill-ins as needed.

1244.  Situation Where Used:

Denial—amount and type of special disregards.

In determining    (1)    eligibility,    (2)    disregarded as follows—    (3)          (4)           (5)   

Fill-ins:

1. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

2. Choice 1 - earned income as a student was

   Choice 2 - income to fulfill a plan to achieve self-support was

   Choice 3 - income used to meet work expenses was

   Choice 4 - income used to meet impairment-related work expenses was

    

3. $$$.¢¢

    

4. Choice 1 - for (Month/Year)

   Choice 2 - for (Month/Year) through (Month/Year)

   Choice 3 - for (Month/Year) on

    

5. Choice 1 - ,

   Choice 2 - and

   Choice 3 - .

   Choice 4 - , and $$$.¢¢for (Month/Year)

   Choice 5 - , and $$$.¢¢for (Month/Year) through (Month/Year)

   Choice 6 - , and $$$.¢¢for (Month/Year) on

NOTE: Repeat fill-ins 2-5 as needed.

1245.  Situation Where Used:

Denial for excess income—ineligible spouse or parent receives public assistance.

The income of    (1)          (2)    does not affect    (3)    eligibility for Supplemental Security Income because    (4)          (5)    public assistance.

Fill-ins:

1. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

2. Choice 1 - parent

   Choice 2 - parents

   Choice 3 - spouse

    

3. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

4. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

5. Choice 1 - parent receives

   Choice 2 - parents receive

   Choice 3 - spouse receives

    

1248.  Situation Where Used:

IC: Award—amount and type of income received by spouse or parents.

PE: Change in income. Record shows deemed income for 1 or more months.

The    (1)    received by    (2)    of    (3)          (4)          (5)   

Fill-ins:

1. Choice 1 - wages

   Choice 2 - Social Security benefits—before any deduction for Medicare Medical Insurance premiums—

   Choice 3 - railroad retirement benefits—before any deduction for Medicare Medical Insurance premiums —

   Choice 4 - black lung benefits

   Choice 5 - Veterans Administration compensation

   Choice 6 - workmen's compensation

   Choice 7 - Veterans Administration pension

   Choice 8 - employment related pension

   Choice 9 - assistance payments based on need

   Choice 10 - rents, interest, dividends, or royalties

   Choice 11 - civil service pension

   Choice 12 - other unearned income

   Choice 13 - support payments from parent

   Choice 14 - military pension

   Choice 15 - net income from self-employment

   Choice 16 - net loss from self-employment

   Choice 17 - Social Security benefits—before deductions for Medicare premiums, if any—

   Choice 18 - railroad retirements benefits—before any deductions for Medicare premiums—

    

2. Choice 1 - your parent

   Choice 2 - your parents

   Choice 3 - your spouse

   Choice 4 - her parent

   Choice 5 - her parents

   Choice 6 - her spouse

   Choice 7 - his parent

   Choice 8 - his parents

   Choice 9 - his spouse

   Choice 10 - (Name of essential person)

    

3. $$$.¢¢

    

4. Choice 1 - for (Month/Year)

   Choice 2 - for (Month/Year) through (Month/Year)

   Choice 3 - for (Month/Year) on

   Choice 4 - or less for (Month/Year)

   Choice 5 - or less for (Month/Year) through (Month/Year)

   Choice 6 - or less for (Month/Year) on

    

5. Choice 1 - ,

   Choice 2 - and

   Choice 3 - .

NOTE: Fill-ins 3-5 repeat as needed.

1249.  Situation Where Used:

IC: Exclusion of income of spouse or parents receiving public assistance.

PE: Change in income. Spouse or parent received public assistance for 1 or more months.

The income of    (1)          (2)    does not affect    (3)    eligibility for Supplemental Security Income payments because    (4)          (5)    public assistance     (6)          (7)   

Fill-ins:

1. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

2. Choice 1 - parent

   Choice 2 - parents

   Choice 3 - spouse

    

3. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

4. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

5. Choice 1 - parent receives

   Choice 2 - parents receive

   Choice 3 - spouse receives

   Choice 4 - parent received

   Choice 5 - parents received

   Choice 6 - spouse received

    

6. Choice 1 - for (Month/Year)

   Choice 2 - for (Month/Year) through (Month/Year)

   Choice 3 - for (Month/Year) on

    

7. Choice 1 - ,

   Choice 2 - and

   Choice 3 - .

NOTE: Fill-ins 6 and 7 repeat as needed.

1252.  Situation Where Used:

IC and PE: This paragraph will be produced following all other income paragraphs whenever paragraphs for unearned income types A, C, E, and/or M are produced.

PE: Change in income.

We must count the full amount of any benefit listed above as income even though all or part of a benefit shown is being withheld to recover an overpayment.

1253.  Situation Where Used:

IC and PE: Countable income includes special one-time payment for 1 or more months.

PE: Change in income.

NOTE: This replaces paragraph 1246.

   (1)    special one-time payment    (2)    received    (3)    of    (4)          (5)    .

Fill-ins:

1. Choice 1 - Your

   Choice 2 - Her

   Choice 3 - His

    

2. Choice 1 - of Social Security benefits—before deduction for Medicare Medical Insurance premiums,—

   Choice 2 - of railroad retirement benefits—before deduction for Medicare Medical Insurance premiums,—

   Choice 3 - of black lung benefits

   Choice 4 - of Veterans Administration compensation

   Choice 5 - of workmen's compensation

   Choice 6 - of Veterans Administration pension

   Choice 7 - of employment related pension

   Choice 8 - of assistance payments based on need

   Choice 9 - of rents, interest, dividends, or royalties

   Choice 10 - of civil service pension

   Choice 11 - of other unearned income

   Choice 12 - of support payment from parent

   Choice 13 - of military pension

   Choice 14 - of support and maintenance

   Choice 15 - of Social Security benefits—before deductions for Medicare premiums, if any

   Choice 16 - of railroad retirement benefits—before any deductions for Medicare premiums—

   Choice 17 - Null

    

3. (Month/Year)

    

4. $$$.¢¢

    

5. Choice 1 - ,

   Choice 2 - and

   Choice 3 - .

NOTE: Fill-in 2-5 repeat as needed.

1254.  Situation Where Used:

IC and PE: Countable income includes special one-time payment received by spouse, parent(s), or essential person for 1 or more months.

PE: Change in income.

NOTE: This replaces paragraph 1247.

   (1)    , the special one-time payment    (2)    received by    (3)          (4)    .

Fill-ins:

1. $$$.¢¢

    

2. Choice 1 - of Social Security benefits—before deduction for Medicare Medical Insurance premiums,—

   Choice 2 - of railroad retirement benefits—before deduction for Medicare Medical Insurance premiums,—

   Choice 3 - of black lung benefits

   Choice 4 - of Veterans Administration compensation

   Choice 5 - of workmen's compensation

   Choice 6 - of Veterans Administration pension

   Choice 7 - of employment related pension

   Choice 8 - of assistance payments based on need

   Choice 9 - of rents, interest, dividends, or royalties

   Choice 10 - of civil service pension

   Choice 11 - of other unearned income

   Choice 12 - of support payment from parent

   Choice 13 - of military pension

   Choice 14 - of support and maintenance

   Choice 15 - of Social Security benefits—before deduction for Medicare premiums, if any

   Choice 16 - of railroad retirement benefits—before any deductions for Medicare premiums—

   Choice 17 - Null

    

3. Choice 1 - your parent

   Choice 2 - your parents

   Choice 3 - your spouse

   Choice 4 - her parent

   Choice 5 - her parents

   Choice 6 - her spouse

   Choice 7 - his parent

   Choice 8 - his parents

   Choice 9 - his spouse

   Choice 10 - (name of essential person)

    

4. in (Month/Year)

    

1257.  Situation Where Used:

IC and PE: Income disregards applied for 1 or more months.

PE: Change in income.

In figuring    (1)    payment    (2)          (3)    was disregarded as follows—    (4)          (5)           (6)   

Fill-ins:

1. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

2. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

   Choice 4 - your spouse

   Choice 5 - her spouse

   Choice 6 - his spouse

   Choice 7 - your parents

   Choice 8 - her parents

   Choice 9 - his parents

    

3. Choice 1 - earned income as a student

   Choice 2 - income to fulfill a plan to achieve self-support

   Choice 3 - income to meet work expenses

   Choice 4 - income used to meet impairment-related work expenses

   Choice 5 - living allowance for ineligible children

    

4. $$$.¢¢

    

5. Choice 1 - for (Month/Year)

   Choice 2 - for (Month/Year) through (Month/Year)

   Choice 3 - for each month, beginning (Month/Year)

    

6. Choice 1 - ,

   Choice 2 - and

   Choice 3 - .

NOTE: Repeat fill-ins 4, 5 and 6 as needed.

1258.  Situation Where Used:

IC and PE: Used to show periods when the individual is subject to the statutory one-third reduction.

The food and shelter    (1)          (2)    in someone else's home or apartment. We value that food and shelter at    (3)          (4)          (5)    .

Fill-ins:

1. Choice 1 - you

   Choice 2 - she

   Choice 3 - he

   Choice 4 - your spouse

   Choice 5 - her spouse

   Choice 6 - his spouse

   Choice 7 - you and your spouse

   Choice 8 - she and her spouse

   Choice 9 - he and his spouse

    

2. Choice 1 - get

   Choice 2 - gets

   Choice 3 - got

    

3. $$$.¢¢(Amount of type J unearned income)

    

4. Choice 1 - for (Month/Year)

   Choice 2 - for (Month/Year) through (Month/Year)

   Choice 3 - for (Month/Year) on

    

5. Choice 1 - ,

   Choice 2 - and

   Choice 3 - .

    

1259.  Situation Where Used:

IC and PE: Used to inform the recipient in FLA-B that he/she may be entitled to more money if they are paying their share of the household expenses.

   (1)    SSI payment has been reduced by    (2)          (3)    . We have done this because    (4)    share of the household expenses. Contact us if you think    (5)    share. We may be able to pay    (6)    more money.

Fill-ins:

1. Choice 1 - Your

   Choice 2 - Her

   Choice 3 - His

    

2. $$$.¢¢(Amount of type J unearned income)

    

3. Choice 1 - for (Month/Year)

   Choice 2 - for (Month/Year) through (Month/Year)

   Choice 3 - for (Month/Year) on

    

4. Choice 1 - you live in someone else's house or apartment and are not paying your

   Choice 2 - she lives in someone else's house or apartment and is not paying her

   Choice 3 - he lives in someone else's house or apartment and is not paying his

    

5. Choice 1 - you are paying your

   Choice 2 - she is paying her

   Choice 3 - he is paying his

    

6. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

    

1260.  Situation Where Used:

IC and PE: Used to tell the recipient and/or his/her spouse what in-kind support and maintenance is charged as income to a recipient in FLA-A.

The food, clothing or shelter    (1)          (2)    from someone. We value the food, clothing or shelter at    (3)          (4)          (5)    .

Fill-ins:

1. Choice 1 - you

   Choice 2 - she

   Choice 3 - he

   Choice 4 - your spouse

   Choice 5 - her spouse

   Choice 6 - his spouse

   Choice 7 - you and your spouse

   Choice 8 - she and her spouse

   Choice 9 - he and his spouse

    

2. Choice 1 - get

   Choice 2 - gets

   Choice 3 - got

    

3. $$$.¢¢(Amount of type H income)

    

4. Choice 1 - for (Month/Year)

   Choice 2 - for (Month/Year) through (Month/Year)

   Choice 3 - for (Month/Year) on

    

5. Choice 1 - ,

   Choice 2 - and

   Choice 3 - .

    

1261.  Situation Where Used:

One-time payment is involved in NO1 decision which results in payment suspension for a future month. Since the system does not compute payment beyond CCM, the system cannot tell whether eligibility will resume in the month CCM +1.

However,    (1)    may be able to get SSI again as soon as     (2)    . If    (3)    not hear from us about this in the next 30 days, contact our nearest office. If    (4)    not get a check, we will be able to tell    (5)    why. And if    (6)    we are wrong,    (7)    can ask us to review our decision.

Fill-ins:

1. Choice 1 - you

   Choice 2 - she

   Choice 3 - he

    

2. (Month/Year)

    

3. Choice 1 - you do

   Choice 2 - she does

   Choice 3 - he does

    

4. Choice 1 - you do

   Choice 2 - she does

   Choice 3 - he does

    

5. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

    

6. Choice 1 - you think

   Choice 2 - she thinks

   Choice 3 - he thinks

    

7. Choice 1 - you

   Choice 2 - she

   Choice 3 - he

    

1280.  Situation Where Used:

IC and PE situations when the retroactive title II check has been issued and it includes payment only for the windfall offset period.

We use    (1)    Social Security money of    (2)    , which    (3)    got in    (4)    , to figure     (5)     SSI payment. We count    (6)    Social Security money as if we paid it to    (7)    during each month it was due. This means we count the money as    (8)          (9)          (10)    . These are the amounts before deductions for Medicare premiums, if any.

Fill-ins:

1. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

   Choice 4 - the

    

2. $$$.¢¢

    

3. Choice 1 - you

   Choice 2 - she

   Choice 3 - he

   Choice 4 - your spouse

   Choice 5 - her spouse

   Choice 6 - his spouse

    

4. (Month/Year)

    

5. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

6. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

   Choice 4 - the

    

7. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

   Choice 4 - your spouse

   Choice 5 - her spouse

   Choice 6 - his spouse

    

8. $$$.¢¢

    

9. Choice 1 - for (Month/Year)

   Choice 2 - a month for (Month/Year) and (Month/Year)

   Choice 3 - a month for (Month/Year) through (Month/Year)

    

10. Choice 1 - ,

    Choice 2 - and

    Choice 3 - .

NOTE: Fill-ins 8, 9 and 10 are used in conjunction with each other to address all the necessary variations when the retroactive title II amounts differ from month to month.

For example: (1) $200 a month for June through September 1985; or

            (2) $200 a month for June 1985, $210 for July 1985, $205 a month for August and September 1985,
                $207 a month for October through December 1985, and $215 for January 1986.

1281.  Situation Where Used:

IC and PE: The retroactive title II check has been issued. Refers only to title II amounts due for the windfall offset period.

   (1)    will soon get Social Security money for past months. When we figure    (2)    SSI payments, we count this Social Security money as if we paid it to    (3)    during each of the months it was due.    (4)    due    (5)          (6)           (7)   

Fill-ins:

1. Choice 1 - You

   Choice 2 - She

   Choice 3 - He

   Choice 4 - Your spouse

   Choice 5 - Her spouse

   Choice 6 - His spouse

    

2. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

3. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

   Choice 4 - your spouse

   Choice 5 - her spouse

   Choice 6 - his spouse

    

4. Choice 1 - You were

   Choice 2 - She was

   Choice 3 - He was

   Choice 4 - Your spouse was

   Choice 5 - Her spouse was

   Choice 6 - His spouse was

    

5. $$$.¢¢

    

6. Choice 1 - for (Month/Year)

   Choice 2 - a month for (Month/Year) and (Month/Year)

   Choice 3 - a month for (Month/Year) through (Month/Year)

    

7. Choice 1 - ,

   Choice 2 - and

   Choice 3 - .

NOTE: Fill-ins 5, 6 and 7 are used in conjunction with each other to address all the necessary variations required when the retroactive title II amounts differ from month to month.

For example: (1) $200 a month for June through September 1985; or

            (2) $200 a month for June 1985, $210 for July 1985, $205 a month for August and September 1985,
                $207 a month for October through December 1985, and $215 for January 1986.

1282.  Situation Where Used:

IC and PE: When the title II retroactive check has been issued and it includes money for months outside the offset period.

IC: It is used with both allowance and denial notices.

PE: This paragraph is generated only once—the month in which the retroactive title II check for the offset period is issued.

We use    (1)    Social Security money of    (2)    , which    (3)    got in    (4)    , to figure     (5)     SSI payment. We count the Social Security money    (6)    got for months before    (7)    , which was the first month    (8)    could get SSI, as income in the month    (9)    got it. Starting with    (10)    , we count the money as if we paid it to    (11)    during the month it was due. This means we count the Social Security money as    (12)          (13)          (14)    . These are the amounts before deductions for Medicare premiums, if any.

Fill-ins:

1. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

   Choice 4 - the

    

2. $$$.¢¢(Amount of the title II retroactive check. This check may include a CMA amount also.)

    

3. Choice 1 - you

   Choice 2 - she

   Choice 3 - he

   Choice 4 - your spouse

   Choice 5 - her spouse

   Choice 6 - his spouse

    

4. (Month/Year)

    

5. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

6. Choice 1 - you

   Choice 2 - she

   Choice 3 - he

   Choice 4 - your spouse

   Choice 5 - her spouse

   Choice 6 - his spouse

    

7. (Month/Year) (first month of SSI eligibility)

    

8. Choice 1 - you

   Choice 2 - she

   Choice 3 - he

    

9. Choice 1 - you

   Choice 2 - she

   Choice 3 - he

   Choice 4 - your spouse

   Choice 5 - her spouse

   Choice 6 - his spouse

    

10. (Month/Year) (same as #7)

     

11. Choice 1 - you

    Choice 2 - her

    Choice 3 - him

    Choice 4 - your spouse

    Choice 5 - her spouse

    Choice 6 - his spouse

     

12. $$$.¢¢

     

13. Choice 1 - for (Month/Year)

    Choice 2 - a month for (Month/Year) and (Month/Year)

    Choice 3 - a month for (Month/Year) through (Month/Year)

     

14. Choice 1 - ,

    Choice 2 - and

    Choice 3 - .

NOTE: Fill-ins 12, 13 and 14 are used in conjunction with each other to address all the necessary variations required when the retroactive title II amounts differ from month to month. The total income addressed in these fill-ins will equal the amount of the retroactive money given in fill-in 2 above.

For example: (1) $200 a month for June through September 1985; or

            (2) $200 a month for June 1985, $210 for July 1985, $205 a month for August and September 1985,
                $207 a month for October through December 1985, and $215 for January 1986.

1601.  Situation Where Used:

IC: Award—amount of chargeable income reduced to zero because of disregards.

PE: Change in income, but no change in payment amount because after exclusions are subtracted, chargeable income remains at zero.

   (1)          (2)    monthly income of    (3)          (4)          (5)    . This amount does not affect    (6)    Supplemental Security Income payment.

Fill-ins:

1. Choice 1 - You

   Choice 2 - You and your parent

   Choice 3 - You and your parents

   Choice 4 - You and your spouse

   Choice 5 - Your parent

   Choice 6 - Your parents

   Choice 7 - Your spouse

   Choice 8 - She

   Choice 9 - She and her parent

   Choice 10 - She and her parents

   Choice 11 - She and her spouse

   Choice 12 - Her parent

   Choice 13 - Her parents

   Choice 14 - Her spouse

   Choice 15 - He

   Choice 16 - He and his parent

   Choice 17 - He and his parents

   Choice 18 - He and his spouse

   Choice 20 - His parent

   Choice 21 - His parents

   Choice 22 - His spouse

   Choice 23 - Your sponsor

   Choice 24 - Her sponsor

   Choice 25 - His sponsor

   Choice 26 - You and your sponsor

   Choice 27 - She and her sponsor

   Choice 28 - He and his sponsor

   Choice 29 - Your sponsor and the spouse of your sponsor

   Choice 30 - Her sponsor and the spouse of her sponsor

   Choice 31 - His sponsor and the spouse of his sponsor

   Choice 32 - You, your sponsor, and the spouse of your sponsor

   Choice 33 - She, her sponsor, and the spouse of her sponsor

   Choice 34 - He, his sponsor, and the spouse of his sponsor

    

2. Choice 1 - have

   Choice 2 - has

   Choice 3 - had

    

3. $$$.¢¢

    

4. Choice 1 - for (Month/Year)

   Choice 2 - for (Month/Year) through (Month/Year)

   Choice 3 - for (Month/Year) on

    

5. Choice 1 - ,

   Choice 2 - and

   Choice 3 - .

    

6. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

NOTE: Fill-ins 3, 4 and 5 repeat as needed.

1602.  Situation Where Used:

IC and PE: Student earned income—monthly disregard.

Earned income of a student may be disregarded up to    (1)    per calendar month but no more than    (2)    for a calendar year.

Fill-ins:

1. Choice 1 - $400.00

   Choice 2 - Null

    

2. Choice 1 - $1,620.00

   Choice 2 - Null

    

1603.  Situation Where Used:

IC and PE: Recipient has net loss from self-employment.

The average monthly amount of    (1)    net loss from self-employment was subtracted from the total of    (2)    other earned income in figuring    (3)    income.

Fill-ins:

1. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

2. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

3. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

1604.  Situation Where Used:

IC and PE: Spouse, parent, or essential person has net loss from self-employment.

The average monthly amount of net loss from self-employment of    (1)    was subtracted from the total of other income of    (2)    in figuring    (3)    income.

Fill-ins:

1. Choice 1 - your parent

   Choice 2 - your parents

   Choice 3 - your spouse

   Choice 4 - her parent

   Choice 5 - her parents

   Choice 6 - her spouse

   Choice 7 - his parent

   Choice 8 - his parents

   Choice 9 - his spouse

   Choice 10 - (Name of Essential Person)

    

2. Choice 1 - your parents

   Choice 2 - your spouse

   Choice 3 - her parents

   Choice 4 - her spouse

   Choice 5 - his parents

   Choice 6 - his spouse

   Choice 7 - (Name of Essential Person)

    

3. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

2230.  Situation Where Used:

Change in income. Parents or spouse no longer receives public assistance.

The income of    (1)          (2)          (3)    must be considered in figuring    (4)    because    (5)           (6)          (7)    public assistance     (8)   

Fill-ins:

1. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

2. Choice 1 - parent

   Choice 2 - parents

   Choice 3 - spouse

    

3. Choice 1 - for (Month/Year)

   Choice 2 - for (Month/Year) through (Month/Year)

   Choice 3 - for (Month/Year) on

    

4. Choice 1 - the amount of your Supplemental Security Income payment

   Choice 2 - the amount of her Supplemental Security Income payment

   Choice 3 - the amount of his Supplemental Security Income payment

   Choice 4 - your eligibility for Supplemental Security Income

   Choice 5 - her eligibility for Supplemental Security Income

   Choice 6 - his eligibility for Supplemental Security Income

    

5. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

6. Choice 1 - parent

   Choice 2 - parents

   Choice 3 - spouse

    

7. Choice 1 - did not receive

   Choice 2 - no longer receive

   Choice 3 - no longer receives

    

8. Choice 1 - for that month

   Choice 2 - for those months

   Choice 3 - .

    

2232.  Situation Where Used:

Change in income but no change in payment amount.

   (1)    payment amount remains the same.

Fill-ins:

1. Choice 1 - Your

   Choice 2 - Her

   Choice 3 - His

    

2523.  Situation Where Used:

Record has been in suspense due to returned checks and claimant remains ineligible because of excess income.

Our review of    (1)    record shows that    (2)    ineligible    (3)          (4)    for Supplemental Security Income payments because of    (5)    income.

Fill-ins:

1. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

2. Choice 1 - you are

   Choice 2 - she is

   Choice 3 - he is

   Choice 4 - you have been

   Choice 5 - she has been

   Choice 6 - he has been

    

3. Choice 1 - beginning

   Choice 2 - since

    

4. (Month/Year)

    

5. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

3028.   Situation Where Used:

The parent-to-child deeming computation changed effective November 1, 1992. However, the system has not yet begun using the new computation. When the system begins using it, this paragraph will be included on a one-time notice to recipients affected by the change.

We use the parents' income to figure the amount of a child's SSI payment. In doing this, we count only part of the parents' income. Beginning November 1992, we changed the way we figure how much of the parents' income we count. As a result, in many cases we count less. This change is the reason    (1)     due more SSI as shown in the above chart.

Fill-ins:

1. Choice 1 - you are

   Choice 2 - she is

   Choice 3 - he is

VA Payments Due to Unusual Medical Expenses

INCM01.  Situation Where Used:

We allowed an initial claim but we are still in the process of verifying that VA is paying for medical expenses. Use on an SSA-L8025-U2, Notice of Award, as the last paragraph under the caption “Information About Your Payments.”

We may owe (1) more SSI money. We're asking the Department of Veterans Affairs (VA) if some of the money they paid (2) was for medical expenses. If so, we won't count that money in figuring (3) SSI payments. We'll write to you again to let you know what VA tells us. Until then, we will count all (4) VA money against (5) SSI payments.

Fill-ins:

1. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

    

2. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

    

3. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

4. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

5. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

INCM02.  Situation Where Used:

VA verifies that the claimant's VA payment includes money for medical expenses. The claimant is due an underpayment or an underpayment and an increase in the recurring payment amount. Use on an SSA-L8100-U2, Notice of Revised Determination or an SSA-L8151-U2, Notice of Change in Payment (for increase in payment), under the caption, “Why Your Payments Changed.” Use paragraph INCM03 below also.

• We owe (1) more SSI money. The Department of Veterans Affairs (VA) told us that (2) VA payments include money for medical expenses. Because (3) of your VA payment for (4) is for medical expenses, we won't count that money in figuring your SSI payments.

• Later in this letter, we'll tell you how much money we counted against (5) SSI payments for the months we changed.

Fill-ins:

1. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

    

2. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

3. (Money amount)

    

4. Choice 1 - (Month/Year)

   Choice 2 - (Month/Year through Month/Year)

   Choice 3 - (Month/Year) on

    

5. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

INCM03.  Situation Where Used:

Same situation as INCM01 above. In addition to using INCM01 paragraphs, use the paragraph shown below as a fill-in under paragraph 1231 in this section. Use under the caption “Your Payment is Based on These Facts.”

(1) VA payments of (2) for (3) . We only count (4) for (5) .

Fill-ins:

1. Choice 1 - Your

   Choice 2 - Her

   Choice 3 - His

    

2. (Money amount)

    

3. Choice 1 - (Month/Year)

   Choice 2 - (Month/Year through Month/Year)

   Choice 3 - (Month/Year) on

    

4. (Money amount)

    

5. Choice 1 - (Month/Year)

   Choice 2 - (Month/Year through Month/Year)

   Choice 3 - (Month/Year) on

    

INCM04.   Situation Where Used:

We have allowed an initial claim but we are still in the process of verifying that VA is paying for medical expenses. Subsequently, we receive verification that the claimant's VA payment does not include money for medical expenses. Use on an SSA-L8166-U2, Notice of Important Information.

We wrote you earlier that we are asking the Department of Veterans Affairs (VA) for additional information about (1) payments from them. We needed to find out if (2) VA payments include money for (3) medical expenses.

WHAT VA TOLD US

VA told us that (4) payments don't include additional money for medical expenses. That means we must count (5) full VA payment of (6) for (7) against your SSI payments. As a result, we have figured your SSI payments correctly.

WHAT YOU SHOULD REMEMBER

If (8) monthly VA payments change to include money for medical expenses, contact us right away. If this is true, (9) may be due more SSI money.

IF YOU HAVE ANY QUESTIONS

If you have any questions, you can call, write or visit any Social Security office. If you call or visit our office, please have this letter with you and ask for (10) . The telephone number is shown at the top of this notice.

Fill-ins:

1. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

2. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

3. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

4. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

5. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

6. (Money amount)

    

7. Choice 1 - (Month/Year)

   Choice 2 - (Month/Year through Month/Year)

   Choice 3 - (Month/Year) on

    

8. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

9. Choice 1 - you

   Choice 2 - she

   Choice 3 - he

    

10. (Claims representative's name)

     

INCM05.   Situation Where Used:

Use for postentitlement cases under force pay when a change in a monthly VA payment, which includes money due to medical expenses, results in an increase or decrease in SSI. Use on an SSA-L8151-U2, Notice of Change in Payment, for an increase or on an SSA-8155-U2, Notice of Planned Action, for a decrease. Use under the caption “Why Your Payments Changed.” Use paragraph INCM06 below also.

• (1) Department of Veterans Affairs (VA) payment changed from (2) to (3) for (4) . Because (5) of your VA payment for (6) is for medical expenses, we won't count that money in figuring your SSI payments.

• Later in this letter, we'll tell you how much money we counted against (7) SSI payments for the months we changed.

Fill-ins:

1. Choice 1 - Your

   Choice 2 - Her

   Choice 3 - His

    

2. (Money amount)

    

3. (Money amount)

    

4. Choice 1 - (Month/Year)

   Choice 2 - (Month/Year through Month/Year)

   Choice 3 - (Month/Year) on

    

5. (Money amount)

    

6. Choice 1 - (Month/Year)

   Choice 2 - (Month/Year through Month/Year)

   Choice 3 - (Month/Year) on

    

7. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

INCM06.   Situation Where Used:

Same situation as INCM04 above. In addition to using INCM04 paragraphs, use the paragraph shown below as a fill-in under paragraph 1231 in this section. Use under the caption “Your Payment is Based on These Facts.”

(1) VA payments of (2) for (3) . We only count (4) for (5) .

Fill-ins:

1. Choice 1 - Your

   Choice 2 - Her

   Choice 3 - His

    

2. (Money amount)

    

3. Choice 1 - (Month/Year)

   Choice 2 - (Month/Year through Month/Year)

   Choice 3 - (Month/Year) on

    

4. (Money amount)

    

5. Choice 1 - (Month/Year)

   Choice 2 - (Month/Year through Month/Year)

   Choice 3 - (Month/Year) on

    

References:

• Plans for Achieving Self Support (PASS), SI 00870.001.

  Exhibit 2—PASS Approval Notice, SI 00870.100

  Exhibit 3—PASS Disapproval Notice, SI 00870.100

• Notice Requirements for PASS Notices—no notice language, SI 00870.100

• PASS approval or periodic review—need for manual notices SSA-L8166-U2 or SSA-L8155-U2, SI 00870.070D. SI 00870.080D

• General instructions about manual SSI offset notices—no notice language, SI 02006.010E.6.

• Notice language for offset with attorney fee involvement, SI 02006.205B.2.b.

• Notice language for offset with attorney involvement—PE situations, SI 02006.215A.3.c.

PASS Approval or periodic review— need for manual notices SSA-L8166 or SSA-L8155, SI 00870.070D and SI 00870.080D

Notice language for offset with attorney fee involvement, SI 02006.205B.2.b.

Notice language for offset with attorney involvement—PE situations, SI 02006.215A.3.c.