NL: Notices, Letters and Paragraphs
TN 3 (02-97)
A. INTRODUCTION
The SSA-L8025-U2 is a manual form with preprinted appeal rights. Select captions and paragraphs from those shown below to produce a complete notice. The SSA-L8025 is also on the DOCS for completing the notice on a personal computer.
B. PROCEDURE
1. Completion of Payment Information
Under the preprinted opening paragraph, is caption 1901, “How Much We'll Pay,” followed by three column headings, “Beginning,” “Through” and “Amount Due.” (paragraph 1011, NL 00804.115).
Under the “Beginning” column enter the month, day and year of application or the protected filing date if earlier than the date of application.
Under the “Through” column enter the last month, day and year that the payment amount continues unchanged. If the same payment amount continues through the current computation month, type “Continuing” instead of a month, day and year.
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Under the “Amount Due” column enter the actual monthly payment amount. When this amount includes a federally administered optional State supplementary payment, include the following statement directly below the amount due:
“(This includes $ from the State of (State Name)/ District of Columbia.)”
Repeat payment information as necessary. Show $00.00 if no payment is due.
2. Chart for Completing the SSA-L8025-U2
The following chart provides a list of additional captions and paragraphs to use when you prepare a manual SSA-L8025-U2.
OUR DECISION ABOUT HOW WE'LL PAY YOU (Caption 1919) (Use this caption and the following paragraphs only if there is representative payee involvement.)
| NL Reference | Paragraph | Use |
|---|---|---|
| 00804.185 | 1291 1609 |
Notices to claimant and representative payee — Choose the appropriate paragraph — SSI payments will go to a representative payee. |
| 1290 1608 |
Notice to representative payee only — Payee's responsibilities. Choose the appropriate paragraph. (See NOTE: under B.5 that tells how to avoid preparing a separate notice to the representative payee.) |
INFORMATION ABOUT YOUR PAYMENTS (Caption 1905) (Mandatory)
| NL Reference | Paragraph | |
|---|---|---|
| A00804.166 | 1623 | Recipient is in an institution, and we are sending the eligibility notice in the second or third month of institutionalization but prior to G/K cutoff for reducing/stopping payment in the fourth month. |
| 1624 | Recipient is in an institution, and we are sending the eligibility notice after G/K cutoff for reducing/stopping payment in the fourth month. | |
| 00804.115 | 1479 | Retroactive in addition to or without ongoing SSI payments due. |
| 1486 | Regular payment due (no retroactive money due). | |
| 1480 1484 |
Claimant has already received payment for a past period — Choose the appropriate paragraph. | |
| 1012 | Lead-in for payment of first check. | |
| 1025 | Claimant has received an advance payment, one-time payment (OTP),and/ or presumptive disability/blindness (PD/PB) payment. Retroactive SSI payment is offset by advance payment, OTP and/or PD/PB payment. | |
| 00804.125 | 1046 | Interim Assistance Reimbursement (IAR) involved (Mandatory if IAR involved). |
| IARM01 1069 |
Six-month exclusion of retroactive SSI payment which is part of an IAR refund check. | |
| 00804.180 | 1270 | Agreement to dispose of excess resources—reminder. |
| 00804.120 | 1040 1041 |
Claimant received advance payments — Choose the appropriate paragraph. |
| 1048 | ||
| 1483 | ||
| 00804.200 | 1370 | Payment due for a retroactive period netted against prior payments. |
| 00804.160 | 1180 MARM55 |
Adjustment of payments due between members of a couple. |
| 1186 MARM56 |
Spouse's application pending. | |
| 00804.130 | 1080 | Filing for other benefits—reminder. |
| 00804.210 | 2526 | Claimant may be due retroactive payments. |
| 1440 1436 |
Overpayment on a prior record — Choose the appropriate paragraph(s). | |
| 1016 1018 |
||
| 1017 | Overpayment on a prior record — Follows paragraph 1436 or 1018, above. | |
| 00804.205 | 1418 1431 |
Making presumptive disability payments pending final determination. |
| 1188 | Award for one member of a couple — presumptive disability payments to other member pending disability determination. | |
| 1432 | Presumptive disability payments stopped after 6 months — final determination pending. | |
| 00804.174 | DCOM03 | Children of Armed Forces personnel who live outside the United States. |
YOUR PAYMENT IS BASED ON THESE FACTS (Caption 1907) (Mandatory)
| NL Reference | Paragraph | Use |
|---|---|---|
| 00804.235 | 1014 | Tells claimant the first day of eligibility for proration Mandatory. |
| 00804.145 | 1130 | Tells claimant category(ies) of eligibility — Mandatory. |
| 1131 | Spouse is eligible for SSI — Tells the spouse's category(ies) of SSI eligibility. | |
| 00804.190 | 1315 | Tells where the claimant resides — Mandatory. |
| 2970 | Says that State rules determine the amount of payment. | |
| 1168 | Describes the State living arrangement. | |
| 00804.160 | 1161 1183 |
Spouse involvement — Choose the appropriate paragraph(s). |
| 1185 MARM54 MARM57 |
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| 00804.155 | 1165 | Describes living arrangement (LA) “C” or “D”. |
| 00804.150 | 1145 | Describes student status of a child. |
| 00804.170 | 1001 1002 |
If sponsor-to-alien deeming applies always use both paragraphs. |
| 00804.174 | DCOM04 | Child is living overseas with a parent who is in the Armed Forces. |
| The following paragraphs address income related issues: | ||
| 00804.175 | 1240 | Claimant has no income/deemed income. |
| 1231 | Income lead-in paragraph. | |
| 1616 | Income lead-in for E01. | |
| 2233 | Lead-in for monthly countable income. | |
| 1280 1281 1282 |
Windfall offset applies — Choose the appropriate paragraph. | |
| If the claimant has income, consider: | ||
| 1601 | Income disregards reduce chargeable income to zero. | |
| 1232 | Describes type, period and amount of countable income. | |
| 1253 | Claimant received a one-time payment of unearned income. | |
| 1260 | Claimant receives in kind support and maintenance. | |
| 1258 | Value of the one-third reduction (VTR) applies. | |
| 1603 | Claimant has a net loss from self-employment. | |
| 1257 | Special income disregards apply for earned and/or unearned income. | |
| 1602 | Student earned income exclusion applies. | |
| 1252 | Overpayment withheld from income other than SSI. (Do not use in the Ninth Circuit.) | |
| If the claimant is subject to deeming, consider: | ||
| 1249 | Spouse or parent(s) receives public assistance — no deemed income. | |
| 1601 | Deemed income does not affect amount of SSI payment. | |
| 1257 | Special income disregards apply for earned and/or unearned income. | |
| 1604 | Spouse or parent(s) has net loss from self-employment. | |
| 1248 | Income of spouse or parent(s) deemed to claimant. | |
| 1234 | Deemor's income deemed to claimant. | |
| 1254 | Spouse or parent(s) received a one-time payment of unearned income. | |
| If the claimant has periods of ineligibility, consider: | ||
| 00804.175 | 1239 | N01 — Claimant has excess income. |
| 00804.165 | 1200 | N02 — Claimant resides in a public institution. |
| 00804.170 | 1216 | N03 — Not residing in U.S. |
| 00804.140 | 1118 | N14 — Claimant has not attained age 65. |
| If the claimant has a period of ineligibility for disability-related reasons, consider: | ||
| 00804.200 | SGAM50 1383 |
Claimant performed substantial gainful activity (SGA) during a closed period. |
| 1373 | Date of onset is later than filing date. | |
| 00804.174 | DCOM04 | Children of Armed Forces personnel who live outside the United States. |
INFORMATION ABOUT YOUR BACK PAYMENTS (Caption 1908) (Use when paragraph 1497 or paragraph DCOM05 below applies.)
| NL Reference | Paragraph | Use |
|---|---|---|
| 00804.180 | 1497 | Claimant will receive a retroactive SSI check(s) and there is no IAR involvement or will receive a retroactive title II check(s)—6-month exclusion from resources applies. |
| 00804.174 | DCOM05 | Children of Armed Forces personnel who live outside the United States. |
ABOUT YOUR OVERPAYMENT (Caption 1909) (Use when the claimant had an overpayment from a prior application or has an overpayment due to advance payments.)
| NL Reference | Paragraph | Use |
|---|---|---|
| 00804.210 | 1441 | Claimant has an overpayment from a prior application. |
| 00804.120 | 1044 1049 |
Choose the appropriate overpayment paragraph. These paragraphs give the amount of SSI paid and the amount that should have been paid. |
| 1043 | Overpayment caused by incorrect advance payment amount — no ongoing payment due. |
IF YOU THINK YOU SHOULDN'T HAVE TO PAY US BACK (Caption 1911) (Mandatory when the preceding caption (1909) is used.)
| NL Reference | Paragraph | Use |
|---|---|---|
| 00804.210 | 1434 | Provides claimant with waiver information — Mandatory with caption 1911. |
INFORMATION ABOUT MEDICAID (AND OTHER BENEFITS)(Caption 1915) (Mandatory) (Use “AND OTHER BENEFITS” in the caption only if paragraph 1311 below is used.)
| NL Reference | Paragraph | Use |
|---|---|---|
| 00804.110 | 1150 1151 1155 1170 |
Choose the appropriate Medicaid referral paragraph for the claimant's State of residence. (Use 1155 only when a claimant is currently ineligible for SSI and resides in a State where an SSI application is also a Medicaid application.) |
| 1146 | Claimant did not provide third-party liability (TPL) information. | |
| 1149 | Claimant did not provide assignment of rights (AOR) information. | |
| 1156 | We are developing for claimant's eligibility under 1619(b). | |
| 1152 | Recipient resides in or moves to a State in which SSA makes Medicaid decisions. Eligibility for payment is suspended or terminated. | |
| 1189 | Potential 1619(b) when an aged individual becomes ineligible due to excess income, has countable earned income and resides in a State for which SSA makes Medicaid determinations. | |
| 1196 | Potential 1619(b) when an aged individual becomes ineligible due to excess income, has countable earned income and resides in a State that makes its own Medicaid determinations. | |
| 1158 | Reporting responsibilities for 1619(b) eligibles in States with Federal Medicaid determinations. | |
| 1159 | Reporting responsibilities for 1619(b) eligibles in States with State Medicaid determinations. | |
| 1142 | Notifies title II widow(er)s age 50-65 who receive SSI of the possibility of special Medicaid eligibility per SI 01715.015B.5. | |
| 1191 1192 1193 |
Reporting information—Use all three paragraphs under paragraph 1158 or 1159 above. | |
| 1166 1167 1179 |
Eligible for closed period. Choose appropriate paragraph. | |
| 1147 | Used only for individuals in State that makes its own Medicaid determinations. Case is referred to State for determination because a Medicaid Qualifying Trust may be involved. This paragraph tells the recipient to contact State Medicaid agency for information. | |
| 00804.174 | DCOM06 | Child living overseas with parent(s) in Armed Forces. |
| 00804.190 | 1311 | Mandatory when the State administers its own supplementation program. |
WHERE YOU CAN APPLY FOR MEDICAID (Use only when you use paragraph 1142 above under the preceding caption.)
| NL Reference | Paragraph | Use |
|---|---|---|
| 00804.110 | 1144 | (Mandatory paragraph for this caption.) Tells title II widow(er) beneficiaries age 50-65 where to apply for Medicaid (SI 01715.015B.5.). |
WE WILL REVIEW YOUR CASE (Caption 1927) (Use only when you have used paragraph 1158 or 1159 above.)
| NL Reference | Paragraph | Use |
|---|---|---|
| 00804.110 | 1190 | (Mandatory paragraph for this caption.) Information for 1619(b) eligibles about continuing disability reviews. |
THINGS TO REMEMBER (Caption 1926) (Mandatory)
| NL Reference | Paragraph | Use |
|---|---|---|
| 00804.240 | 1482 1615 |
(Mandatory paragraph.) Notifies eligible claimants about reporting responsibilities. Choose the appropriate paragraph. |
| 1620 | Advises claimant to report changes even though no SSI payments due now. | |
| 1481 | Advises the claimant to refile if he/she believes he/she can qualify for SSI. | |
| 1487 | Title II decision will be in a separate notice. | |
| 1000 | Refers to an additional notice in either English or Spanish. | |
| 00804.245 | 1598 | No title II (or additional title II) benefits payable. |
| 00804.220 | 2834 | Value of the one-third reduction (VTR) may not apply if claimant begins to pay pro-rata share of expenses. |
| 00804.130 | 1606 | Claimant must file for other benefits. |
| 00804.174 | DCOM01 | Blind or disabled children living overseas should contact SSA when they return to the United States. |
| 00804.210 | 1438 | Claimant may be overpaid. |
| 00804.190 | 1313 | Claimant waived SSA-administered optional State supplement payment. |
| 00804.160 | 1181 | Spouse also filed for SSI and will receive a separate notice. |
| 00804.150 | 1456 | Child is age 18 and does not attend school regularly or over 18 but under 21 and stops attending school regularly. |
| 00804.200 | 1414 1415 1424 1425 |
Choose the appropriate paragraph to tell a disabled/blind claimant about continuing disability reviews. |
| 00804.205 | 1419 | Reminder to cooperate. Presumptive disability payments made. |
| 00804.185 | 2489 | Representative payee will receive a copy of notice. |
| 00804.207 | 1650 | Introduces paragraph 1651, the enclosure, “SSI RULES THAT HELP SSI RECIPIENTS WORK.” |
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DO YOU DISAGREE WITH THE DECISION?/HOW TO APPEAL/IF YOU WANT HELP WITH YOUR APPEAL (Paragraph 1726) (Mandatory)
Appeal rights are preprinted as part of the manual SSA-L8025-U2 and also appear on the FONS version of the notice.
IF YOU HAVE ANY QUESTIONS (Caption (Unnumbered)) (Mandatory)
| NL Reference | Paragraph | Use |
|---|---|---|
| 00804.240 | MISM53 | Closing paragraphs (Mandatory) —Choose the appropriate paragraph. |
| 1704 | Refers to enclosure(s) — Mandatory | |
| 00804.174 | DCM02 | Use on ALL notices to children living overseas. |
3. Signature
Close the notice as follows:
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Name of Manager
Title
4. Enclosures
Always enclose the pamphlet, “When You Get SSI... What You Need To Know.” (Pub 05-11011)
If the claimant is age 14 or older and blind or disabled, enclose “SSI Rules That Help You Work” (NL 00804.207, paragraph 1651).
Always enclose the pamphlet, “A Guide for Representative Payees” (Pub 05-10076) when the notice is sent to the representative payee.
Two lines under “Title,” at the left margin, type “Enclosure(s)” and list the enclosures, starting a new line for each one. (If you need a copy of the notice for the representative payee, see the note under 5 below before typing this.)
5. 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, appointed representative and/or legal guardian or other person who is required to get a copy. 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.
NOTE: When you must send both the representative payee and the claimant a copy of the award notice, add the caption, “Our Decision About How We'll Pay (Claimant's Name)” to the representative payee's copy below the signature line at the left hand margin. Insert paragraph 1290 or 1608 here instead of in the body of the notice. (If you do this, you will not have to prepare two separate notices.)
C. REFERENCE
Preparation of a Manual Notice, NL 00801.010 ff.