TN 25 (02-95)

2021. Situation Where Used:

In rare situations, the system identifies an input for one month only which affects the budget month and causes the due amount to be reduced or suspended. However, payment is protected per Goldberg/Kelly at the old rate. In these cases, the system will issue this paragraph on an SSA-L8100.

Even though (1) for (2) , we will not (3) (4) payment of (5) . This is to give (6) time to appeal this decision. However, you may have to pay back any money (7) not eligible to receive. We will let you know later if payment for (8) changes. (9)

1. Choice 1 - you are not due any money

   Choice 2 - she is not due any money

   Choice 3 - he is not due any money

   Choice 4 - you are due only ($$$.¢¢)

   Choice 5 - she is due only ($$$.¢¢)

   Choice 6 - he is due only ($$$.¢¢)

    

(2) (Month/Year)

3. Choice 1 - stop

   Choice 2 - reduce

    

4. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

(5) $$$.¢¢

6. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

    

7. Choice 1 - you are

   Choice 2 - she is

   Choice 3 - he is

    

(8) (Month/Year)

9. Choice 1 - In spite of the above, we must withhold all of the amount we would have sent because excess payments were previously received.

   Choice 2 - In spite of the above, we will send ($$$.¢¢) and withhold ($$$.¢¢) because excess payments were previously received.

   Choice 3 - Null

    

2022. Situation Where Used:

Payment is being adjusted, advance notice is required.

Even though (1) for (2) , we would (3) (4) payment. This was to give (5) time to appeal this decision. However, because (6) overpaid previously, we must (7) withhold (8) (9) . We will let you know later if payment for (10) changes.

1. Choice 1- you are not due any money

   Choice 2 - she is not due any money

   Choice 3 - he is not due any money

   Choice 4 - you are due only ($$$.¢¢)

   Choice 5 - she is due only ($$$.¢¢)

   Choice 6 - he is due only ($$$.¢¢)

    

2. (Month/Year)

    

3. Choice 1 - not have stopped

   Choice 2 - not have reduced

   Choice 3 - have sent

    

4. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

   Choice 4 - you a

   Choice 5 - your representative payee a

    

5. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

    

6. Choice 1 - you were

   Choice 2 - she was

   Choice 3 - he was

    

7. Choice 1 - continue to

   Choice 2 - Null

    

8. Choice 1 - all of the ($$$.¢)

   Choice 2 - ($$$.¢¢) and will send ($$$.¢¢)

    

9. Choice 1 - to your bank or other financial institution

   Choice 2 - Null

    

10. (Month/Year)

     

2370. Situation Where Used:

Recipient appeals—payment maintenance applicable.

We will pay (1) (2) a month while (3) (4) request (5) is being considered.

1. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

   Choice 4 - your representative payee

    

2. $$$.¢¢

    

3. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

4. Choice 1 - reconsideration

   Choice 2 - hearing

   Choice 3 - appeal

    

5. Choice 1 - of (Month/Year)

   Choice 2 - Null

    

2371. Situation Where Used:

Recipient appeals and requests payment maintenance for only selected factors. (No supplemental check or OTP.) (Used with paragraphs 2370 and 2375.)

This payment amount, as you requested, is based on changes in (1) case other than those involved in 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

    

2372. Situation Where Used:

Recipient is in payment maintenance—subsequent action causes a new payment due which is different from the established prior payment level.

We have determined that beginning (1) (2) monthly payment amount should be (3) . But we will (4) (5) , until a decision is made on all determinations still under appeal.

1. (Month/Year)

    

2. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

3. $$$.¢¢

    

4. Choice 1 - pay you

   Choice 2 - pay her

   Choice 3 - pay him

   Choice 4 - pay your representative payee

   Choice 5 - continue to pay you

   Choice 6 - continue to pay her

   Choice 7 - continue to pay him

   Choice 8 - continue to pay your representative payee

    

5. $$$.¢¢

    

2373. Situation Where Used:

Recipient is in payment maintenance—subsequent action (other than excess income) causes suspension or termination (fill-in 3, choices 1, 2, or 3); or, the new payment due is greater than the prior payment level (fill-in 3, choices 4, 5, or 6).

This determination regarding (1) Supplemental Security Income eligibility is different from the determination (2) appealing. (3)

1. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

2. Choice 1 - you are

   Choice 2 - she is

   Choice 3 - he is

    

3. Choice 1 - We will stop your check as shown above unless you also appeal this determination.

   Choice 2 - We will stop her check as shown above unless you also appeal this determination.

   Choice 3 - We will stop his check as shown above unless you also appeal this determination.

   Choice 4 - When a decision is made on your appeal, we will let you know if it changes this new payment amount.

   Choice 5 - When a decision is made on her appeal, we will let you know if it changes this new payment amount.

   Choice 6 - When a decision is made on his appeal, we will let you know if it changes this new payment amount.

    

2375. Situation Where Used:

Recipient appeals adverse action—notification of potential overpayment.

Depending on the outcome of (1) appeal, (2) may have to pay back any money (3) not eligible to receive.

1. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

2. Choice 1 - you

   Choice 2 - she

   Choice 3 - he

    

3. Choice 1 - you are

   Choice 2 - she is

   Choice 3 - he is

    

2377. Situation Where Used:

Recipient appeals and requests payment maintenance the same month the State terminates contract for Federal administration of State supplement.

This payment amount is based on (1) payment in (2) less (3) which was from the (4) . The (5) has decided to administer its own supplement and will now send (6) a separate monthly check for any additional money due (7) .

1. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

2. (Month/Year)

    

3. $$$.¢¢

    

4. Choice 1 - State of  

   Choice 2 - District of Columbia

    

5. Choice 1 - State of  

   Choice 2 - District of Columbia

    

6. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

   Choice 4 - your representative

    

7. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

    

2381. Situation Where Used:

Adverse action occurs—notification of payment continuation.

Recipient appeals and requests payment maintenance for only selected factors—OTP or supplemental payment made.

(1) should receive a check for (2) within a few days. This is what we will continue to pay (3) each month until (4) is decided.

1. Choice 1 - You

   Choice 2 - Your representative payee

    

2. $$$.¢¢

    

3. Choice 1 - you

   Choice 2 - your representative payee

    

4. Choice 1 - your reconsideration

   Choice 2 - her reconsideration

   Choice 3 - his reconsideration

   Choice 4 - your hearing

   Choice 5 - her hearing

   Choice 6 - his hearing

   Choice 7 - your appeal

   Choice 8 - her appeal

   Choice 9 - his appeal

    

2841. Situation Where Used:

Standard appeal paragraph on all SSA-L8155's.

NOTE: This replaces paragraph 2374.

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

Manual Paragraphs

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

    

GBKM01. Situation Where Used:

Recipient appeals and requests payment maintenance—OTP or supplemental payment made.

You should receive a separate check for (1) within a few days. This is the difference between what you received or will shortly receive (2) and what (3) continued monthly payment will be until (4) is decided.

1. $$$.¢¢

    

2. Choice 1 - for (Month/Year)

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

    

3. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

4. Choice 1 - your reconsideration

   Choice 2 - her reconsideration

   Choice 3 - his reconsideration

   Choice 4 - your hearing

   Choice 5 - her hearing

   Choice 6 - his hearing

   Choice 7 - your appeal

   Choice 8 - her appeal

   Choice 9 - his appeal

    

GBKM02. Situation Where Used:

Recipient is in payment maintenance status—State terminates contract for Federal administration of State supplement. (Federal and State money previously payable.)

We have been sending (1) (2) while  (3) (4) is being considered. This included  (5) from the (6) . The (7) has decided to administer its own supplement and will now send (8) a separate monthly check for any additional money due (9) .

1. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

   Choice 4 - your representative payee

    

2. $$$.¢¢

    

3. Choice 1 - your reconsideration

   Choice 2 - her reconsideration

   Choice 3 - his reconsideration

   Choice 4 - your hearing

   Choice 5 - her hearing

   Choice 6 - his hearing

   Choice 7 - your appeal

   Choice 8 - her appeal

   Choice 9 - his appeal

    

4. Choice 1 - of (Month/Year)

   Choice 2 - Null

    

5. $$$.¢¢

    

6. Choice 1 - State of  

   Choice 2 - District of Columbia

    

7. Choice 1 - State of  

   Choice 2 - District of Columbia

    

8. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

   Choice 4 - your representative payee

    

9. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

    

GBKM03. Situation Where Used:

Recipient is in payment maintenance status—State terminates contract for Federal administration of State supplement. (State money only previously payable.)

We have been sending (1) (2) while  (3) (4) is being considered. This check was for money from the (5) . The (6) has decided to administer its own supplement and will now send (7) a monthly check for any money due (8) .

1. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

   Choice 4 - your representative payee

    

2. $$$.¢¢

    

3. Choice 1 - your reconsideration

   Choice 2 - her reconsideration

   Choice 3 - his reconsideration

   Choice 4 - your hearing

   Choice 5 - her hearing

   Choice 6 - his hearing

   Choice 7 - your appeal

   Choice 8 - her appeal

   Choice 9 - his appeal

    

4. Choice 1 - (of (Month/Year)

   Choice 2 - Null

    

5. Choice 1 - State of   

   Choice 2 - District of Columbia

    

6. Choice 1 - State of   

   Choice 2 - District of Columbia

    

7. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

   Choice 4 - your representative payee

    

8. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

    

GBKM04. Situation Where Used:

Recipient requests payment maintenance the same month the State terminates contract for Federal administration of State supplement. (State supplement only payable.)

The money we have been sending (1) from the (2) only. The (3) has decided to administer its own supplement and will now send (4) a check each month for any money due (5) .

1. Choice 1 - you was money due you

   Choice 2 - you was money due her

   Choice 3 - you was money due him

   Choice 4 - your representative was money due you

    

2. Choice 1 - State of   

   Choice 2 - District of Columbia

    

3. Choice 1 - State of   

   Choice 2 - District of Columbia

    

4. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

   Choice 4 - your representative payee

    

5. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

    

GBKM05. Situation Where Used:

Death of one member of an eligible couple. Prior adverse action for both members for which payment maintenance is in effect.

Because (1) requested appeal within 10 days of our earlier determination to (2) (3) payments, we continued (4) payments pending outcome of that appeal.  (5) paid (6) even though (7) entitled to (8) . Because we have not yet made a decision on (9) appeal, we will continue to pay (10) (11) , although (12) now (13) as an individual.

1. Choice 1 - you and your spouse

   Choice 2 - she and her spouse

   Choice 3 - he and his spouse

    

2. Choice 1 - stop

   Choice 2 - reduce

    

3. Choice 1 - your

   Choice 2 - their

4. Choice 1 - your

   Choice 2 - their

5. Choice 1 - You were

   Choice 2 - She was

   Choice 3 - He was

6. $$$.¢¢

7. Choice 1 - you were

   Choice 2 - she was

   Choice 3 - he was

8. $$$.¢¢

9. Choice 1 - your

   Choice 2 - their

10. Choice 1 - you

    Choice 2 - her

    Choice 3 - him

11. $$$.¢¢

12. Choice 1 - you are

    Choice 2 - she is

    Choice 3 - he is

13. Choice 1 - entitled to $$$.¢¢

    Choice 2 - not eligible

     

GBKM06. Situation Where Used:

Use to stop multiple payments and pay the correct amount. Use on an SSA-L8165-U2, Important Information, under the caption, “[Your/(Recipient's Name)] Payment Is Based On These Facts.” Use paragraph GBKM08 for appeal language.

By mistake, we have been sending you more than one monthly SSI check. Our records show that we paid (1) the following checks:

(2) for (3)

Based on the facts we have, we should have paid (4) :

(5) for (6)

Beginning (7) we will send you only one monthly payment.

1. Choice 1 - you
   Choice 2 - her
   Choice 3 - him

2. $$$.¢¢ (amount of check)

3. Month/Year (date check paid)

4. Choice 1 - you
   Choice 2 - her
   Choice 3 - him

5. $$$.¢¢ (amount that should have been paid)

6. same as (3)

7. Month/Year (date of payment)

NOTE: For fill-ins (2) for (3) and (5) for (6), show all check amounts. For example:

• $325 for March 1993

  $195 for March 1993

  $350 for April 1993

  $195 for April 1993

   

GBKM07. Situation Where Used:

Use to correct erroneous payments over the payment ceiling and pay the correct amount. Use on an SSA-L8165-U2, Important Information, under the caption, “[Your/(Recipient's Name)] Payment Is Based On These Facts.” Use paragraph GBKM08 for appeal language.

By mistake, we sent you SSI check(s) for the wrong amount. This amount was more than the highest SSI check we could pay a person in (1) situation.

Our records show that we paid (2) :

(3) for (4)

Based on the facts we have, we should have paid (5) :

(6) for (7)

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

2. Choice 1 - you
   Choice 2 - her
   Choice 3 - him

3. $$$.¢¢ (amount of check)

4. Month/Year (date of payment)

5. Choice 1 - you
   Choice 2 - her
   Choice 3 - him

6. $$$.¢¢ (amount that should have been paid)

7. Same as (4)

NOTE: If more than one month is involved, repeat the fill-ins in a column. For example:

• $395 for March 1993
  $395 for April 1993
  $350 for May 1993

   

GBKM08. Situation Where Used:

Use this appeal language with paragraph GBKM06 or GBKM07 on an SSA-L8165-U2, Important Information, when correcting erroneous payment. DO NOT use the 10-day payment continuation caption and paragraph in certain payment ceiling cases when there is no right to payment continuation during appeal. (See SI 02301.315.E for instructions.)

NOTE: This paragraph replaces paragraph 2551 (NL 00804.224) in this situation.

Do You Disagree With The Decision?

If you disagree with the decision, you have the right to appeal. We will review your case and consider any new facts you have.

• You have 60 days to ask for an appeal.

• The 60 days start the day after you get this letter. We assume you got this letter 5 days after the date on it unless you show us that you did not get it within the 5-day period.

• You must have a good reason for waiting more than 60 days to to ask for an appeal.

• You have to ask for an appeal in writing. We will ask you to sign a Form SSA-561-U2, called “Request for Reconsideration.” Contact one of our offices if you want help.

   

Appeal In 10 Days To Receive A Monthly Check For (1)

• If you appeal within 10 days we will send you monthly checks for (2) . This is the most we can pay (3) while we look at (4) appeal.

• The 10 days start the day after you get this letter. We assume you got this letter 5 days after the date on it unless you show us that you did not get it within the 5-day period.

• If you lose your appeal, you might have to pay back some or all of this money.

   

How To Appeal

There are three ways to appeal. You can pick the one you want. If you meet with us in person, it may help us decide your case.

• Case Review. You have a right to review the facts in your file. You can give us more facts to add to your file. Then we will decide your case again. You will not meet with the person who decides your case. This is the only kind of appeal you can have to appeal a medical decision.

• Informal Conference. You will meet with the person who decides your case. You can tell that person why you think you are right. You can give more facts to help prove you are right. You can bring other people to help explain your case.

• Formal Conference. This is a meeting like an informal conference. The difference is we can make people come to help prove you are right. We can make them bring important papers about your case, even if they do not want to help you. You can question these people at your meeting.

If You Want Help With Your Appeal

You can have a friend, lawyer or someone else help you. There are groups that can find you a lawyer or give you free legal services if you qualify. There are also lawyers who do not charge unless you win your appeal. Your local Social Security office has a list of groups that can help you with your appeal.

If you get someone to help you, you should let us know. If you hire someone, we must approve the fee before he or she can collect it.

1. $$$.¢¢ (amount of check)

2. Same as (1)

3. Choice 1 - you
   Choice 2 - her
   Choice 3 - him

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

REFERENCE:

Erroneous Payments and Payment Continuation—manual notice instructions,
SI 02301.315