TN 25 (02-95)

2801. Situation Where Used:

Used in both November and January COLA notices where the new amount due is an increase, decrease, or reinstatement.

The amount due    (1)    beginning    (2)    will be    (3)    .    (4)          (5)    .

1. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

    

2. (Month/Year)

    

3. $$$.¢¢

    

4. Choice 1 - This amount includes $$$.¢¢

   Choice 2 - Null

    

5. Choice 1 - from the State of Alabama

   Choice 2 - from the State of Alaska

   Choice 3 - from the State of Arizona

   Choice 4 - from the State of Arkansas

   Choice 5 - from the State of California

   Choice 6 - from the State of Colorado

   Choice 7 - from the State of Connecticut

   Choice 8 - from the State of Delaware

   Choice 9 - from the District of Columbia

   Choice 10 - from the State of Florida

   Choice 11 - from the State of Georgia

   Choice 12 - from the State of Hawaii

   Choice 13 - from the State of Idaho

   Choice 14 - from the State of Illinois

   Choice 15 - from the State of Indiana

   Choice 16 - from the State of Iowa

   Choice 17 - from the State of Kansas

   Choice 18 - from the State of Kentucky

   Choice 19 - from the State of Louisiana

   Choice 20 - from the State of Maine

   Choice 21 - from the State of Maryland

   Choice 22 - from the State of Massachusetts

   Choice 23 - from the State of Michigan

   Choice 24 - from the State of Minnesota

   Choice 25 - from the State of Mississippi

   Choice 26 - from the State of Missouri

   Choice 27 - from the State of Montana

   Choice 28 - from the State of Nebraska

   Choice 29 - from the State of Nevada

   Choice 30 - from the State of New Hampshire

   Choice 31 - from the State of New Jersey

   Choice 32 - from the State of New Mexico

   Choice 33 - from the State of New York

   Choice 34 - from the State of North Carolina

   Choice 35 - from the State of North Dakota

   Choice 36 - from the State of Ohio

   Choice 37 - from the State of Oklahoma

   Choice 38 - from the State of Oregon

   Choice 39 - from the State of Pennsylvania

   Choice 40 - from the State of Rhode Island

   Choice 41 - from the State of South Carolina

   Choice 42 - from the State of South Dakota

   Choice 43 - from the State of Tennessee

   Choice 44 - from the State of Texas

   Choice 45 - from the State of Utah

   Choice 46 - from the State of Vermont

   Choice 47 - from the State of Virginia

   Choice 48 - from the State of Washington

   Choice 49 - from the State of West Virginia

   Choice 50 - from the State of Wisconsin

   Choice 51 - from the State of Wyoming

   Choice 52 - Null

    

2802. Situation Where Used:

In rare cases, the system will issue a COLA notice to records in Goldberg/ Kelly payment maintenance, but manual inputs and a manual notice are also required.

We have determined that beginning    (1)          (2)    monthly payment amount should be    (3)    . But we will pay     (4)          (5)    until a decision is made on all determinations still under appeal. Depending on the outcome of    (6)    may have to pay back any money    (7)    not eligible to receive.

1. (Month/Year)

    

2. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

3. $$$.¢¢

    

4. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

    

5. $$$.¢¢

    

6. Choice 1 - your appeal, you

   Choice 2 - her appeal, she

   Choice 3 - his appeal, he

    

7. Choice 1 - you are

   Choice 2 - she is

   Choice 3 - he is

    

2803. Situation Where Used:

Used in November and January COLA notices where eligibility terminates due to excess income.

   (1)    will stop in    (2)    .

1. Choice 1 - Your check

   Choice 2 - Her check

   Choice 3 - His check

   Choice 4 - Your eligibility

   Choice 5 - Her eligibility

   Choice 6 - His eligibility

    

2. (Month/Year)

    

2804. Situation Where Used:

Used in November COLA notices when SSI payment is decreased or suspended because of income.

Even though the law provides for an increase in Supplemental Security Income payments beginning    (1)          (2)          (3)     .    (4)          (5)   

(1) (Month/Year)

2. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

3. Choice 1 - payment will be lowered

   Choice 2 - payment will be lowered because of your income

   Choice 3 - payment will be lowered because of her income

   Choice 4 - payment will be lowered because of his income

   Choice 5 - payment will be stopped

   Choice 6 - payment will be stopped because your income will be too high for you to receive payments

   Choice 7 - payment will be stopped because her income will be too high for her to receive payments

   Choice 8 - payment will be stopped because his income will be too high for him to receive payments

    

4. Choice 1 - This is because there will be an increase in the amount of Social Security benefits in (Month/Year) which we must count in figuring your Supplemental Security Income payment.

   Choice 2 - This is because there will be an increase in the amount of Social Security benefits in (Month/Year) which we must count in figuring her Supplemental Security Income payment.

   Choice 3 - This is because there will be an increase in the amount of Social Security benefits in (Month/Year) which we must count in figuring his Supplemental Security Income payment.

   Choice 4 - Null

    

5. Choice 1 - Your income will be too high for you to receive payments.

   Choice 2 - Her income will be too high for her to receive payments.

   Choice 3 - His income will be too high for him to receive payments.

   Choice 4 - Null

    

2805. Situation Where Used:

Used in November COLA notices when there is an SSI payment increase or reinstatement due to COLA.

   (1)    the law provides for an increase in Supplemental Security Income payments in    (2)    if there was an increase in the cost-of-living during the past    (3)    .

1. Choice 1 - The amount due you is being raised because

   Choice 2 - The amount due her is being raised because

   Choice 3 - The amount due him is being raised because

   Choice 4 - In starting your payments again, we have increased the amount of your check because

   Choice 5 - In starting her payments again, we have increased the amount of her check because

   Choice 6 - In starting his payments again, we have increased the amount of his check because

   Choice 7 - Your payment is being started again because

   Choice 8 - Her payment is being started again because

   Choice 9 - His payment is being started again because

    

2. (Month/Year)

    

3. Choice 1 - year

   Choice 2 - 6 months

    

2807. Situation Where Used:

Used for November COLA notices for SSA-L8151's only. Income lead-in when there is an SSI increase or reinstatement and a change in income on the record.

Our records show that the following income used to figure    (1)    payment has also changed—

1. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

2811. Situation Where Used:

Used in November or January COLA, where new SSI due is $0 due to excess income N01.

If at any time in the future you think    (1)    for payment, please contact us immediately. If    (2)    not eligible to receive payment for a month before    (3)    ,    (4)    will have to file a new application to receive payment. Since we cannot make payment for a month before the month in which an application is filed, a delay in applying will result in a loss of payment for months before the application is filed.

1. Choice 1 - you qualify

   Choice 2 - she qualifies

   Choice 3 - he qualifies

    

2. Choice 1 - you are

   Choice 2 - she is

   Choice 3 - he is

    

3. (Month/Year)

    

4. Choice 1 - you

   Choice 2 - she

   Choice 3 - he

    

2813. Situation Where Used:

In rare cases, the system will issue a notice to records where Goldberg/ Kelly payment maintenance is applicable. Manual action and manual notices are still required for these records.

This determination regarding    (1)    Supplemental Security Income eligibility is different from the determination    (2)    appealing.

1. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

2. Choice 1 - you are

   Choice 2 - she is

   Choice 3 - he is

    

2814. Situation Where Used:

The individual has title II income.

   (1)    increased Social Security benefits—before deductions for Medicare premiums, if any, of    (2)    .    (3)    should receive the increased check about    (4)    .    (5)   

1. Choice 1 - Your

   Choice 2 - Her

   Choice 3 - His

    

2. $$$.¢¢

    

3. Choice 1 - You

   Choice 2 - She

   Choice 3 - He

    

4. (Month/Day/Year)

    

5. Choice 1 - We must count the increase in your benefits for (Month/Year) even though we are counting your other income for (Month/Year).

   Choice 2 - We must count the increase in her benefits for (Month/Year) even though we are counting her other income for (Month/Year).

   Choice 3 - We must count the increase in his benefits for (Month/Year) even though we are counting his other income for (Month/Year).

    

2815. Situation Where Used:

Specific income paragraph—title II income of spouse.

The increased Social Security benefits, before deductions for Medicare premiums, if any, of    (1)    received by    (2)    spouse. This increased check should be received about    (3)    . We must count the increase in the benefits of    (4)    spouse even though we are counting the other income, if any, for    (5)    .

1. $$$.¢¢

    

2. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

3. (Month/Day/Year)

    

4. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

5. (Month/Year)

    

2816. Situation Where Used:

Overpayment being recovered by withholding.

The amount shown above is the amount we would send    (1)    each month if we were not recovering an overpayment.

1. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

    

2817. Situation Where Used:

Overpayment recovery is completed with the adjustment of the COL check.

The amount due    (1)    as shown above is the amount we would send each month if we were not recovering an overpayment. By withholding     (2)    from the amount due    (3)    , we have completed recovery of the overpayment.    (4)    payment amount will be    (5)    for    (6)    . Beginning    (7)    we will pay you    (8)    full monthly payment.

1. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

    

2. $$$.¢¢

    

3. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

    

4. Choice 1 - Your

   Choice 2 - Her

   Choice 3 - His

    

5. $$$.¢¢

    

6. (Month/Year)

    

7. (Month/Year)

    

8. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

2818. Situation Where Used:

Overpayment recovery causes reduction in amount of ongoing check.

The amount due    (1)    as shown above is the amount we would send each month if we were not recovering an overpayment. We will continue to withhold    (2)    each month until the overpayment of    (3)     remaining after    (4)    , is recovered.    (5)    payment will be    (6)    beginning    (7)    . Please get in touch with any Social Security office if you disagree with the rate of withholding or if you prefer to make refund.

1. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

    

2. $$$.¢¢

    

3. $$$.¢¢

    

4. (Month/Year)

    

5. Choice 1 - Your

   Choice 2 - Her

   Choice 3 - His

    

6. $$$.¢¢

    

7. (Month/Year)

    

2819. Situation Where Used:

Overpayment recovery not completed. Recovery action causes payment amount to be reduced to zero.

The amount due    (1)    as shown above is the amount we would send if we were not recovering an overpayment. Since the rate of recovery previously established is greater than the amount due, we will withhold all of the amount due    (2)    until the remaining overpayment of     (3)    is recovered. Please get in touch with any Social Security office if you disagree with this rate of withholding or if you prefer to make refund.

1. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

    

2. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

    

3. $$$.¢¢

    

2820. Situation Where Used:

In November or January COLA when payment is suspended. Remainder of overpayment should be refunded.

We have been withholding    (1)          (2)    monthly payment to recover an overpayment. Because    (3)    no longer due payment as shown above, we can no longer recover the overpayment by withholding    (4)    payments. Therefore, you should refund     (5)    , the remainder of the overpayment. Make    (6)    check or money order payable to the Social Security Administration, Social Security number    (7)    , and mail it to any Social Security office. If you cannot refund the full amount, please get in touch with any Social Security office about making monthly installments.

1. Choice 1 - part of

   Choice 2 - Null

    

2. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

3. Choice 1 - you are

   Choice 2 - she is

   Choice 3 - he is

    

4. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

5. $$$.¢¢

    

6. Choice 1 - your

   Choice 2 - a

    

7. (Recipient's Social Security Number)

    

2829. Situation Where Used:

Specific income paragraph—spouse, parent, or essential person has title II income.

The increased Social Security benefit of    (1)    for    (2)     . Medical insurance premiums are deducted from this benefit. This increased check was paid    (3)    about    (4)    .

1. $$$.¢¢

    

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. 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

    

4. (Month/Year)

    

2831. Situation Where Used:

Close-out paragraph—retention of eligibility in nonpayment cases. Even though    (1)    not due payments,    (2)    still considered to be eligible under the Supplemental Security Income program. You should continue to report any event that might affect    (3)    eligibility or allow    (4)    to receive payments again.

1. Choice 1 - you are

   Choice 2 - she is

   Choice 3 - he is

    

2. Choice 1 - you are

   Choice 2 - she is

   Choice 3 - he is

    

3. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

4. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

    

2833. Situation Where Used:

IC and PE: Used to show periods when the individual is subject to the statutory one-third reduction for January COLA notices only.

The food and shelter    (1)          (2)    in someone else's home or apartment. We raised the value of this food and shelter to    (3)    beginning in    (4)    because there was a cost-of-living increase in SSI payments.

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 spoouse

    

2. Choice 1 - receive

   Choice 2 - receives

   Choice 3 - received

    

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

    

4. (Month/Year)

    

2834. Situation Where Used:

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

   (1)    living in someone else's home or apartment. We may be able to pay    (2)    more SSI money if    (3)    paying    (4)    share of the household expenses. Contact us if you think    (5)    paying    (6)    share.

1. Choice 1 - You are

   Choice 2 - She is

   Choice 3 - He is

    

2. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

    

3. Choice 1 - you are

   Choice 2 - she is

   Choice 3 - he is

    

4. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

5. Choice 1 - you are

   Choice 2 - she is

   Choice 3 - he is

    

6. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

2835. Situation Where Used:

Individual has type H income—used in January notice re March payment.

The food, clothing or shelter (1) (2) from someone else. We raised the value of this food, clothing or shelter to (3) beginning (4) because there was a cost-of-living increase in SSI payments.

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 - receive

   Choice 2 - receives

   Choice 3 - received

3. $$$.¢¢

4. (Month/Year)

    

2836. Situation Where Used:

Lead-in paragraph for any income on the record.

NOTE: This paragraph replaces 2806 and 2809.

Our records show (1) total monthly income which was used to figure (2) SSI payment for (3) is (4) . This is based on the following income—

1. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

2. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

3. (Month/Year)

4. $$$.¢¢

    

2837. Situation Where Used:

Describes the effect of January income on March payment, i.e., RMA. Used in January COLA notices only.

We normally use income from 2 months earlier when we figure (1) SSI payment for a month. In this case, we use income from January to figure (2) payment for March.

1. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

2. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

2841. Situation Where Used:

Standard appeal paragraph on all SSA-L8155's.

We won't change (1) check if (2) within 10 days after getting this notice.

1. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

2. Choice 1 - you appeal

   Choice 2 - she appeals

   Choice 3 - he appeals

   Choice 4 - either you or your spouse appeals

   Choice 5 - either she or her spouse appeals

   Choice 6 - either he or his spouse appeals

    

2844. Situation Where Used:

OBSOLETE

Signature line

Dorcas R. Hardy,

Commissioner of Social Security

2845. Situation Where Used:

OBSOLETE

Signature line

Herbert R. Doggette, Jr.

Deputy Commissioner, Operations

2846. Situation Where Used:

OBSOLETE

Signature line

Gwendolyn S. King,

Commissioner of Social Security

Manual Paragraphs

COLM50. Situation Where Used:

An appeal is pending and the record is in protected payment status. COLA recomputation results in an increase or decrease in the recipient's protected payment level (PPL). If the PPL increases, use on an SSA-L8151-U2, Notice of Change in Payment, following paragraphs 2801 and 2805. If the PPL decreases, use on an SSA-L8155-U2, Notice of Planned Action, following paragraphs 2801 and 2804. Use under the caption, “Information About [Your/(Recipient's Name)] Payments.”

We have not decided about (1) appeal. (2) will receive the (3) SSI payment until we make a decision. If (4) appeal, (5) may have to pay back some or all of this money. We will send you another letter to let you know about (6) appeal.

1. Choice 1 - your
   Choice 2 - her
   Choice 3 - his

2. Choice 1 - You
   Choice 2 - She
   Choice 3 - He

3. Choice 1 - higher
   Choice 2 - lower

4. Choice 1 - you lose your
   Choice 2 - she loses her
   Choice 3 - he loses his

5. Choice 1 - you
   Choice 2 - she
   Choice 3 - he

6. Choice 1 - your
   Choice 2 - her
   Choice 3 - his

REFERENCES:

COLA coordination notice language and sample notice, SI 02005.015 D.2., 3.

COLA recomputation—correcting the PPL, SI 02301.325 D.

How to correct the PPL during appeal (including COLA), SI 02301.325—manual notice instructions