I-2-8-99.Exhibit - SSI Payment Status Request

Last Update: 9/2/05 (Transmittal I-2-63)

SSI Payment Status Request - Please Expedite

Part I. (To be completed by AC)

The case of the individual named below has been remanded to an Administrative Law Judge for further proceedings. A copy of the remand order is attached.

a. _____________________ b. _______________________ SSN

Individual's Name

c. _____________________

Date of Remand Order

d. _____________________________

Date of Prior Request for Hearing

e. ______________________________

Date of Prior Decision or Dismissal Order

f. This case was remanded to:

___________________________________________ HO

___________________________________________ Address

___________________________________________

___________________________________________

___________________________________________Telephone (with area code)

___________________________________________

Name of Hearing Office Manager or other contact person

 

 

Part 2. (To be completed by FO)

So that the individual may be promptly notified of his or her rights to continued payments, please perform SSI queries, check off the appropriate category and refer to POMS DI 12027.065 for further instructions.

(Check one)

___

a.

Individual received continued payments before at the ALJ hearing level, but is not receiving payments now. HO will send notice in I-2-8-100 Exhibit. FO will take necessary actions regarding redetermination of nondisability factors and reinstatement of continued payments. Retroactive payments may begin for the first month of nonpayment following the date of the prior decision or dismissal order shown in Part 1.e. If the individual wants to waive continued payments, the FO will have the individual complete a written waiver, which will be sent to the HO for association with the CF.

___

b.

Individual received continued payments before at the ALJ hearing level, and is receiving payments now. HO will send notice in I-2-8-101 Exhibit. No FO action necessary to reinstate payments, which should continue uninterrupted as long as the individual continues to meet the nondisability requirements of eligibility. If the individual wants to waive continued payments, the FO will have the individual complete a written waiver, which will be sent to the HO for association with the CF, and the FO will stop the payments.

___

c.

Individual did not receive continued payments before at the ALJ hearing level. HO will send notice in I-2-8-102 Exhibit. If the individual contacts the FO to request continued payments, the FO will have the individual complete a written request, which will be sent to the HO for association with the CF. FO will take necessary actions regarding redetermination of nondisability factors and starting continued payments, which may begin for the month of the remand order shown in Part 1.c.

Please telephone the HO shown in Part 1.f. above and send them a copy of this form as followup. For the telephone contact give the following information:

Name of individual (Part 1.a.)

SSN (Part 1.b.)

Date of Remand Order (Part 1.c.)

Which category checked off in Part 2. above (a. or b. or c.)

Name and telephone number of FO staff person making the call.