TN 8 (12-07)

A. Policy

SSA must issue a dated written notice to:

• Advise the claimant/recipient of potential eligibility to other program benefits;

• Explain how eligibility for SSI will be affected if he/she does not file for and take the necessary action to receive the other benefit; and

• Issue a dated SSA-L8050-U3.

1. When to Use Form SSA-L8050-U3

Form SSA-L8050-U3 (SSI Claim Information Notice) is used to:

• Notify the claimant/recipient of the requirements and consequences of not filing for the other benefits by the date indicated (30 days after notice is given to an individual, 35 days if the SSA-L8050-U3 is mailed). See SI 00510.030 for an exhibit;

• Obtain immediate acknowledgement by an agency that an individual has applied or has refused to apply for a benefit and when to expect an agency's decision on an individual's eligibility for a benefit; and

• Obtain a report from an agency on its decision of eligibility for benefits.

NOTE: For claims taken on MSSICS, the SSA-L8050-U3 is generated based on answers to questions on the BMEN and its detail screens. (See MSOM MSSICS 019.002 thru MSOM MSSICS 019.014, and MSOM MSSICS 024.002 for information on completion of these screens and the printing of the SSA-L8050-U3).

2. Specific Situations

a. Other Benefit is Title II

See SI 00510.021 for the notice to issue when the other benefit is Title II.

b. Claimant Preference

If an individual prefers not to use the referral form for other benefit inquiries, we may accept as proof of filing:

• A photocopy of the application for the other program benefit; or

• A receipt for filing an online application for the other program benefit; or

• The notice of decision on the other program benefit application; or

• A letter from the potential payer stating the individual has filed.

B. Procedure — Completing Form SSA-L8050-U3

Complete an SSA-L8050-U3 for each benefit type to which the claimant/recipient is potentially entitled as follows:

1. First Page — Referral Notice

• First blank, enter the time period for filing (the date is 30 calendar days from the date that the notice is given to the claimant or, 35 days if the notice is mailed).

• Second blank, enter the date the notice was received or mailed. This date will represent the first month an overpayment begins if the individual does not comply with the filing requirement.

NOTE: The entry is different when the notice is mailed during the last 5 days of the month; e.g., date of notice is 10/31/07, assume receipt is 5 days after date on notice, or 11/3/07. Therefore, the individual will have to repay any payments received beginning with the month of November. (See SI 00510.001B.)

• Organization Name and Address -- Enter the full name and address of the organization or agency which the individual must contact in “Organization Name and Address” Field at the bottom of the page.

NOTE: When contacting the Railroad Retirement Board (RRB) use the address of the RRB office serving your area, not of RRB, Chicago.

2. Second Page — FO Copy

Use the second page as a control copy for follow-up purposes.

3. Third Page — Request For Information

Use the third page to explain to the organization why it is necessary for the individual to file for the program benefits it administers.

4. Fourth Page — Request For Information

Complete the fourth page after removing carbons (if not MSSICS generated).

1. Part 1: Obtain the claimant's/recipient's signature and the date of signature for every information request.

2. Part 2: If the claimant/recipient is the person upon whose work or service the claim for payment is based, check the block beside “The Claimant” and enter the requested information for the claimant/recipient.

If the claimant/recipient is not the person upon whose work or service the claim is based:

• Check the second block, and

• Enter the name of the person, and

• Show his/her relationship to the person whose work or service is material to the claim.

If answers to any items are not available, enter "Unknown" in the appropriate block.

3. Part 3: The agency or organization completes this section.

C. Procedure — Routing the SSA-L8050-U3 (For Non-Title II Benefits)

1. Remove the carbons (if not MSSICS generated) and complete Part 2 of the last page, as explained in SI 00510.020 B.4.b. above. Be sure the claimant/recipient signs and dates Part 1.

2. Route the completed pages as follows:

   • Give or send to the SSI claimant/recipient pages 1, 3, and 4 of the SSA-L8050-U3.

     NOTE: The claimant/recipient may elect to take or send page 3 to the source of the potential other benefits. It is his/her responsibility to apply for the other benefit within the specified time limit (30 or 35 days as appropriate), and provide the FO with documentation of filing, such as a SSA-L8050–U3 signed and completed by the benefit source or a receipt for an online benefit application.

   • Consider attaching form SSA-L1103 (SSI Request for Information) to the SSA-L8050-U3 when referring an individual to the VA and unusual medical expenses (see SI 00830.312), augmentation (see SI 00830.314), or aid and attendance or a housebound allowance (see SI 00830.308) is involved. When following this procedure, annotate the SSA-L1103 “to be used if application approved.” See SI 00830.320 for instructions on the completion of the SSA-L1103).

   • Give or mail the SSA-L8050-U3 to the individual and, as appropriate a return envelope along with the “Claim Information Notice” to deliver to the organization or agency directly if he/she wishes.

   • Retain the “FO Copy” for control purposes.

   • Follow procedures in SI 00510.025C and D to monitor compliance and document determination.

D. References

• Diary Process, SM 01301.200

• Diary Process-Claims Active in MSSICS, SM 01301.205

• Diary Process-claims not Active in MSSICS, SM 01301.210

• Manually Prepared Notices - General, NL 00801.010

• Use of the SSA-L8050-U3, SI 00510.020.A.1