TN 14 (03-05)

A. Introduction

Standard protective filing closeout notices are available for closing out both written statements of intent to file and oral inquiries. The closeout notices contained in this section are preprinted in English and Spanish. The notices, as well as the paragraphs in NL 00804.245, are available on the Document Preparation System (DPS) in English and Spanish. The English versions of the application cover notices are also automated in the Modernized Supplemental Security Income Claims System (MSSICS). The English version of the SSA-L991, informal denial notice, is automated in the 800 Number System.

B. Policy

1. Addressee

The closeout notice is issued to the claimant.

EXCEPTIONS:

• If the claimant is deceased, the notice is issued to the parent or spouse eligible to receive the underpayment.

• If the claimant is a minor child under age 18 or legally incompetent, issue the closeout notice to the inquirer. However, if the child is a proper applicant per GN 00204.003B.2.b., issue it to the child.

2. Dates

All dates entered on closeout notices must be shown in date format; e.g., April 5, 2003.

3. Signature Requirements

The employee preparing the closeout notice must sign the Manager's name at the end of the notice above the title, "Manager."

C. Procedure

1. Protective Writing

Issue a manual closeout notice on a SSA-L8165, Important Information, using the appropriate language in NL 00804.245.

2. Oral Inquiry

a. SSA-L991 Notice

Close out oral inquiries with an SSA-L991-U3 or SSA-L991-U3-SP when the situation in SI 00601.037B.3.a., SI 00601.037B.3.b., SI 00601.037B.3.e., SI 00601.037B.3.f. or SI 00601.037B.3.h. applies.

The 800 Number System automated SSA-L991 or DPS versions should be issued when the situation in SI 00601.037B.3.e. or SI 00601.037B.3.f. applies because these versions contain the alternative opening paragraph and denial reason for missed/cancelled appointments that were not rescheduled.

The reason for the informal denial must be that the inquirer does not want to file. If the claimant appears ineligible based on other factors of eligibility, include them in the notice.

REMINDER: If the notice is prepared in DPS, be sure to send a copy via DPS to the ORS. See SI 00601.040C.3. for additional instructions.

EXCEPTION: If the inquiry is made on behalf of a child under age 18 or a legally incompetent adult, issue a closeout notice using the notice language in NL 00804.245, APIM51. See SI 00601.040C.3. for preparing the notice in DPS.

b. Application Cover Notices

If the situation in SI 00601.037B.3.g. applies, include the appropriate application cover notice in SI 00601.040C.5. with the application that is sent to the applicant for signature.

NOTE: 800 Number agents should refer to TC 10005.040 of the Teleservice Center Operating Guide (TSCOG) for instructions on completing the SSA-L305-U3 (TSC). Follow the instructions in SI 00601.040C.3. for preparing the notice in DPS.

c. Manual Closeout Notices

Issue a closeout notice using the appropriate language in NL 00804.245 when the situation in SI 00601.037B.3.c. or SI 00601.037B.3.d. applies. See SI 00601.040C.3. for preparing the notice in DPS.

d. Protective Filing closeout in iAppt

Protective filing closeout language and the closeout period ending date(s) appear on the iAppt confirmation page. See GN 00203.016 for additional information. The FO should not send any protective filing closeout notice because the online language closes out the:

• Title XVI protective filing established when the claimant responds “Yes” to the “Would you also be interested in Supplemental Security Income (SSI)” question on iAppt; and

• Title XVI oral inquiry when the claimant indicates there is no intent to file for SSI.

3. Documentation

If a manual or DPS protective filing closeout notice is issued, annotate the 800 Number System Worksheet, MSSICS DW01 screen or paper title XVI application per SI 00601.037B.4. If a DPS notice is prepared, send a copy to ORS so it will be retained on that system. There is no need to retain a copy of the notice. If there is any question about whether a protective filing closeout notice was issued, check the ORS system for a copy of the notice.

See GN 00201.005F.2. for documenting the title II MCS or paper application when a SSA-L991 is issued because the title II claimant does not wish to file for SSI.

4. Completion of SSA-L991-U3

Tear off the perforated tab at the top of the notice to separate pages 1, 2 and 3 before completing.

a. Identifying Information

• Enter the addressee's name and address on the left.

• Office Address: Enter the field office (FO) address.

• Office Hours: Enter the hours the FO is open to the public.

• Telephone Number: Enter the FO telephone number.

• Date: Enter the date you give or mail the notice to the addressee.

• Social Security Number (SSN): Enter the claimant's SSN.

b. First Paragraph

• First entry: Enter the date of the oral inquiry (month/day/year).

• Second entry: Enter either

  • you (if the individual is the addressee), or

  • the name of the inquirer.

c. Why You Are Not Eligible

Place an "X" in the appropriate block(s) that indicate the reason(s) for ineligibility. Block 5 must always contain an X as one of the reasons for ineligibility (see SI 00601.040C.2.a.).

• Block 3: Enter the amount of monthly income.

• Block 4: First entry: Enter the value of the resources.

• Block 4: Second entry: Enter the current resource limit.

• Block 5: Enter either

  • you (if the individual is the addressee), or

  • name of the inquirer

• Block 6: Enter any other reason(s) for ineligibility not listed in blocks 3-5.

d. Why You May Want To File A Claim

Enter the date (month/day/year) that is 60 calendar days after the date of the notice. If the 60th day falls on a nonworkday, the protective filing closeout period ends on the following workday.

e. If You Have Any Questions

Enter the name of the contact person in the space provided.

Attach the enclosure exhibited in SI 00601.040E. if the informal denial is based on excess income or resources.

5. Applications Cover Notices

If a preprinted manual application cover notice or DPS version must be prepared, see SI 00601.037B.4. for the documentation requirements.

Systems Limitation: The cover notice option does not appear on the Print Options screen in the MSSICS redetermination path. Therefore, a MSSICS automated cover notice cannot be issued when an eligible individual with an ineligible spouse is on the supplemental security income record and the ineligible spouse is now applying. In this situation, issue a DPS or preprinted application cover notice. If DPS is used send a copy of the notice to ORS.

a. SSA-L8024

Issue a SSA-L8024 to the applicant when a supplemental security income (SSI) application is completed but not signed and you need additional information/evidence.

NOTE: Use the DPS or preprinted version of the SSA-L8024-U3 SP when a paper Spanish application form, SSA-8000-BK SP, is completed. See SI 00601.037B.7. for when to issue a follow up copy of the notice. The preprinted cover notice, SSA-L8024-U3, contains an original, follow up and file copy.

b. SSA-L305

Issue a SSA-L305 to the applicant when a SSI application is completed but not signed and no additional information/evidence is needed. 800 Number agents should complete the manual version of the SSA-L305-U3 (TSC).

NOTE: Use the DPS or preprinted version of the SSA-L305-U3 SP when the Spanish version of the paper abbreviated application form, SSA-8001-BK SP, is completed. See SI 00601.037B.7. for when to issue a follow up copy of the notice. The preprinted SSA-L305-U3 and SSA-L305-U3 (TSC) notices contain an original, follow up and file copy. 800 Number agents should refer to the TSCOG for completion instructions on issuing the preprinted SSA-L305-U3 TSC.

6. Completion of the preprinted SSA-L8024-U3

Tear off the perforated tab at the top of the notice to separate pages 1 and 2 before completing.

a. Identifying Information

See SI 00601.040C.3.a. for completing this information at the top of the notice.

If a follow up copy must be issued per SI 00601.037B.7., enter the date it is issued after “Second Request Date."

b. First Paragraph

• First Entry

  Date of interview (month/day/year).

• Second Entry

  • you (if the individual is the addressee), or

  • the name of the inquirer.

• Third Entry

  Enter either:

  • your (if the individual is the addressee), or

  • his or her

c. Things We Need

• First Paragraph

  Enter the date (month/day/year) the information/evidence must cover.

• Place an "X" in the appropriate block(s).

  Blocks 1-2

  Enter either:

  • the name of the person for whom you are requesting the evidence (e.g., the claimant, worker, spouse, bank account holder), or

  • you (if the individual is the addressee).

  Block 3

  First entry

  Enter the date (month/day/year) of the first pay stub.

  Second entry:

  Enter either:

  • the name of the person for whom you are requesting the evidence, or

  • you (if the individual is the addressee).

  Blocks 4-10

  Enter either:

  • the name of the person for whom you are requesting the evidence, or

  • you (if the individual is the addressee).

  Block 11

  Enter any other pertinent information not specifically listed on the notice.

d. If We Do Not Hear From You

Enter the date (month/day/year) that is 60 calendar days after the date of the notice. If the 60th day falls on a nonworkday, the protective filing closeout period ends on the following workday.

e. If You Have Any Questions

Enter the name of the contact person in the space provided.

7. Completion of the preprinted SSA-L305-U3

Tear off the perforated tab at the top of the notice to separate pages 1 and 2 before completing.

See SI 00601.040C.3.a. for completing the information at the top of the notice.

If a follow up copy must be issued per SI 00601.037B.7., enter the date it is issued after “Second Request Date.”

a. First Paragraph

• First entry

  Enter the date (month/day/year) of the interview.

• Second Entry

  Enter either:

  • you (if the individual is the addressee), or

  • the name of the inquirer.

• Third entry

  Enter either:

  • your (if the individual is the addressee), or

  • his or her.

b. If We Do Not Hear From You

Enter the date (month/day/year) that is 60 calendar days after the date of the notice. If the 60th day falls on a nonworkday, the protective filing period ends on the next workday.

c. If You Have Any Questions

Enter the name of the contact person.

D. Examples

The following examples illustrate closing out oral inquiries and determining the correct filing date when multiple contacts with SSA are involved:

EXAMPLE 1: Mr. Hall calls the local SSA office on 7/1, to inquire about SSI. After the service representative (SR) explains the program, Mr. Hall decides not to file. The SR documents the oral inquiry on the 800 Number System and issues an automated SSA-L991-U3 to Mr. Hall. The notice advises Mr. Hall that he has until 8/30 to file or he may lose benefits. After receiving the SSA-L991-U3, Mr. Hall calls the teleservice center (TSC) on 8/1 stating that he now wishes to file. The discussion of Mr. Hall's SSI eligibility represents a new oral inquiry. The TSR establishes the 8/1 oral inquiry on a new 800 Number System Worksheet and makes a teleclaim appointment for 8/15.

On 8/15 the claims representative (CR) takes a SSI MSSICS application and selects the 7/1 800 Number protective filing date from the MSSICS Lead screen as Mr. Hall's protective filing date. The CR explains to Mr. Hall that he must return the signed application by 8/30 or he may lose benefits. The CR mails the application along with an automated SSA-L305-U3 application cover notice to Mr. Hall. The notice will close out the 8/1 oral inquiry on 10/14 (60 days after the date on the SSA-L305-U3) should Mr. Hall fail to return the signed application.

Mr. Hall mails his signed application to SSA on 10/16. The FO receives the application on 10/18. The envelope contains a postmark date of 10/16. Since the 7/1 and 8/1 oral inquiries are closed out, the CR checks the postmark date. Since the postmark date would not result in a more advantageous filing date than the actual receipt date, the CR enters 10/18, the actual receipt date, in RECEIVED on the MSSICS DW01 screen and in EFFECTIVE FILING DATE on the ACLM screen.

EXAMPLE 2: Mr. Hall calls the local SSA office on 7/1, to inquire about SSI. After the service representative (SR) explains the program, Mr. Hall decides not to file. The SR documents the oral inquiry on the 800 Number System and issues an automated SSA-L991-U3 to Mr. Hall. The notice advises Mr. Hall that he has until 8/30 to file or he may lose benefits. After receiving the SSA-L991-U3, Mr. Hall calls the teleservice center (TSC) on 8/1 stating that he now wishes to file. The discussion of Mr. Hall's SSI eligibility represents a new oral inquiry. The TSR establishes the 8/1 oral inquiry on a new 800 Number System Worksheet and makes a teleclaim appointment for 8/15.

Mr. Hall calls the TSC on 8/14 to reschedule his 8/15 appointment. His new appointment is for 8/18. On 8/17 Mr. Hall calls the TSC to reschedule his 8/18 appointment. He states that he must reschedule his appointment after 8/23. The TSR explains to Mr. Hall that he may lose benefits if he does not file his application by 8/30. Mr. Hall is given an in-office appointment for 8/28 because there is insufficient time to process a teleclaim before the expiration of Mr. Hall's protective filing period (8/30). The 8/14 and 8/17 telephone calls do not constitute new oral inquiries since they were requests to reschedule his teleclaim appointments. The TSR annotates the 8/1 Worksheet with the second rescheduled appointment date. The CR, upon receipt of the updated 800 Number System referral on 8/17, sends Mr. Hall an automated SSA-L991-U3 notice because he rescheduled his application appointment twice. The closeout notice will closeout the 8/1 oral inquiry if Mr. Hall doesn’t return his signed application before 10/16. Mr. Hall kept his 8/28 in-office appointment completing and signing his application that day. His filing date is established as July 1.

EXAMPLE 3: Same situation as Example 2 except Mr. Hall does not keep the 8/28 in-office appointment. The FO attempts to contact Mr. Hall using the procedures in SI 00601.037D. The CR was able to reach him by telephone on 8/29 and completed a SSI teleclaim. The CR sent Mr. Hall the completed application to sign and a SSA-L305-U3 application cover notice. The SSA-L305-U3 will close out the 8/1 oral inquiry on 10/28 if Mr. Hall fails to return his signed application by this date. The CR explains to Mr. Hall that if he returns his signed application to us by 8/30, we will use 7/1 as his application filing date. The CR further explains to Mr. Hall that if he returns the application after this date but by 10/28, we will use 8/1 as his application filing date. Mr. Hall's signed application is received in the FO on 9/15. The CR establishes his application filing date as 8/1.

E. Exhibits

1. SSA-L991-U3

Social Security Administration

Supplemental Security Income

Important Information

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.

[_] You are not age 65 and are not blind or disabled.

[_] You are not a U.S. citizen, national, or eligible alien.

[_] 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.)

[ ] _____________________ told us that you do not want to file a claim for SSI.

(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.

Manager

Enclosure

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 for SSI.

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 for SSI.

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.

SSA-L991-U3 (8-97)

2. SSA-L8024-U3

Social Security Administration

Supplemental Security Income

Important Information

On ____________________, we talked with __________________ about your eligibility for Supplemental Security Income (SSI). We filled out the enclosed application for SSI based on _______________ statements. However, we cannot decide if you are eligible until you sign the application and give us more information.

What You Need To Do

• Answer any questions circled on the application.

• Correct any information that is wrong.

• Sign and date the application in the space called "Your Signature." If your husband or wife is also applying for SSI, please have him or her sign in the space called "Spouse's Signature."

• Mail or bring us the application and the information requested below along with this letter. If you mail the application and information, please use the enclosed postage paid envelope.

Things We Need

We need to see all of the items checked below from ___________________ to the present. We will help you get anything you do not have.

[_] Bank statements: savings and checking accounts, and any other bank statements for ________________________________________________

[_] Pension records from: the Department of Veterans Affairs, Railroad Retirement Board, Civil Service, State, military, private pensions for__________________________________________________________________

[_] Pay stubs from work since ____________________ for _________________

[_] For self-employment, last year's income tax return; if not available, all records that show last year's business income and expenses for__________________________________________________________________

See Next Page

Form SSA-L8024-U3 (9-92)

Prior Editions May Be Used

Page 2 of 2

[_] Unemployment compensation payment records for ___________________

[_] Worker's compensation award letter for ______________________

[_] Life insurance policies for _______________________________

[_] Birth certificate for ____________________________________

[_] Citizenship papers for __________________________________

[_] Burial contract agreement for _____________________________

[_] Other _____________________________________________________________

______________________________________________________________________

We must see the original document(s) or a certified copy of these item(s). We cannot accept photocopies. We will return these items to you.

If We Do Not Hear From You

It is important that you sign your application and return it to us right away. Send it to us even if you do not have all the information. The sooner we get your signed application, the sooner we can decide if you are eligible. You could lose benefits if you return your application to us after _____________________.

If You Have Any Questions

If you have any questions, you may 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 is shown at the top of this letter.

Also, if you plan to visit, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

Manager

Enclosure(s):

Application

Return Envelope

Form SSA-L8024-U3 (9-92)

Prior Editions May Be Used

3. SSA-L305-U3

Social Security Administration

Supplemental Security Income

Important Information

On ________________, we talked with _______________________ about your eligibility for Supplemental Security Income (SSI). We filled out the enclosed application for SSI based on ______________________ statements. However, we cannot decide if you are eligible until you sign the application and give us more information.

What You Need To Do

• Answer any questions circled on the application.

• Correct any information that is wrong.

• Sign and date the application in the space called "Your Signature." If your husband or wife is also applying for SSI, please have him or her sign in the space called "Spouse's Signature."

• Mail the application to us at the address shown above in the enclosed postage paid envelope.

If We Do Not Hear From You

It is important that you sign your application and return it to us right away. The sooner we get your signed application, the sooner we can decide if you are eligible. You could lose benefits if you return your application to us after ______________________________.

If You Have Any Questions

If you have any questions, you may 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 is shown above. Also, if you plan to visit, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

Manager

Enclosures:

Application

Return Envelope