Form SSA-L8125-F6 Supplemental Security Income Notice of Interim Assistanc

Form Approved
OMB No. 0960-0546

Social Security Administration

Supplemental Security Income
Notice of Interim Assistance Reimbursement
Date:
Claim Number:

GRCODE:

Action Required By The State
Complete the State's Account of Reimbursement Claimed section by using the information
in the "Retroactive Amount Due Summary." Return all but this page within 10 working days

IAR-PAYMENT PENDING CASE
Social Security Administration

Things To Remember When Determining Your Amount of Reimbursement
Federally Reimbursable Interim Assistance (lA) is assistance from State or local funds
to an individual for meeting basic needs during the period beginning with the first
month for which such individual received an SSI dollar amount payment; or,
beginning with the first day for which the individual's benefits were suspended or
terminated, if the individual was subsequently found to have been eligible for such
payments, and paid an SSI dollar amount ending with (and including) the month
I

You may recoup the assistance you paid for any month in a period as defined above for
which both SSI and lA payments were made. You may not recoup for any months prior
to the month in which you began paying lAin this period. If a month is not listed in the
"Retroactive Amount Due Summary" you cannot recoup the assistance you paid for
that month. However, if you have prepared and cannot stop delivery of the last
assistance payment that you made to an individual when you receive this notice from
SSA, you may recoup that assistance payment even though it is not listed in the
"Retroactive Amount Due Summary."

Form SSA-L8125-F6 (4-2012) EF (4-2012)

Page2
In cases where SSI payments were prorated, you must prorate the amount you recover
for that month. You may only recoup the prorated amount of the full lA payable for that
month. A month's amount is prorated if the day is other than the first of the month.
Assistance payments financed in whole or part from Federal funds (e.g., TANF)
do not come within the meaning of interim
assistance.
Privacy Act Statement
Collection and Use of Personal Information
Title 16 Section 1631 (g) of the Social Security Act, as amended, authorizes us to collect
this information. We will use the information you provide to determine the amount of
interim assistance necessary to reimburse the state. The information you furnish on this
form is voluntary. However, failure to provide the requested information may prevent
an accurate and timely decision on the amount of reimbursement. We rarely use the
information you supply for any purpose other than for determining reimbursements.
However, we may use it for the administration and integrity of Social Security programs.
We may also disclose information to another person or to another agency in
accordance with approved routine uses, which include, but are not limited to the
following:

See revised
Privacy Act
Statement and
PRA

1. To enable a third party or an agency to assist Social Security in establishing rights to
Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and Department of
Veterans' Affairs);
3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure
the integrity of Social Security programs.

We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, or local
government agencies. Information from these matching programs can be used to establish or
verify a person's eligibility for Federally-funded or administered benefit programs and for
repayment of payments or delinquent debts under these programs. A complete list of routine
uses for this information is available in our System of Records Notice entitled, Supplemental
Security Income Record and Special Veterans Benefits, 60-0103. This notice, additional
information regarding this form, and information regarding our programs and systems, are
available on-line at http:/ /www.socialsecurity.gov or at your local Social Security office.

Paperwork Reduction Act Statement- This information collection meets the requirements of 44 U.S.
C. §3507, as amended by section 2 of the Paperwork Reduction Act of 1995 . You do not need to
answer these questions unless we display a valid Office of Management and Budget (OMB) control
number. The OMB control number for this collection is 0960-0546. We estimate that it will take
between 30 minutes to read the instructions, gather the facts, and answer the questions. Send only

comments relating to our time estimate above to: SSA, 640 7 Security Blvd, Baltimore,
Form SSA-l8125-F6 (4-2012) EF (4-2012)

Form Approved
OMB No. 0960-0546

Page 3

IAR PAYMENT PENDING CASE STATE DUE
PAYMENT******PRIORITY HANDLING COMPLETE &
RETURN WITHIN 10 WORKING DAYS:
**********************CLAIMANT INFORMATION**********************
Initial Claim

Posteligibility Claim

Recipient's N a m e - - - - - - - - - - - - - - - - -

Other

--------

SSN - - - - - - - - - -

Representative Payee's Name (If applicable)
Date of SSI Eligibility:
Amount of SSI Retroactive Benefits Due:
Amount and Month of Recurring SSI Payment:
TO: (Social Security Administration Address)

**********STATE'S ACCOUNT OF REIMBURSEMENT CLAIMED**********
Date Returned To SSA

Welfare Telephone #

GRCode

AMOUNT
1. Amount of interim assistance paid to the individual

AMOUNT
2. Amount of reimbursement claimed by the
~t::ltP

MONTH/YEAR
3. First month for which State paid lA during the interim period
I certify that the above is an accurate statement of the amount of assistance paid and the amount of
reimbursement claimed in accordance with our agreement negotiated pursuant to P.L. 93-368, as amended.
Signature

Title and Agency

Date

**************************************************************************

To Be Completed by SSA:
SSA Telephone Number
Amount of reimbursement check released to the
State
Date

----------------

Form SSA-l8125-F6 (4-2012) EF (4-2012)

By

Page4
*****************RETROACTIVE AMOUNT DUE SUMMARY*****************

Recipient's Name - - - - - - - - - - - - - - - Recipient's SSN

FROM

THROUGH

Form SSA-L8125-F6 (4-2012) EF (4-2012)

AMOUNT EACH MONTH

PageS
*****************RETROACTIVE AMOUNT DUE SUMMARY*****************

Recipient's Name - - - - - - - - - - - - - - - Recipient's SSN

FROM

THROUGH

Form SSA-L8125-F6 (4-2012) EF (4-2012)

AMOUNT EACH MONTH

Page6

*****************RETROACTIVE AMOUNT DUE SUMMARY*****************

Recipient's Name - - - - - - - - - - - - - - - Recipient's SSN

FROM

THROUGH

Form SSA-L8125-F6 (4-2012) EF (4-2012)

AMOUNT EACH MONTH

SSA will insert the following revised Privacy Act Statement into the form at its
next scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information
Section 1631(g), of the Social Security Act, as amended, authorizes us to collect this
information. We will use the information you provide to determine the amount of interim
assistance to reimburse the State or local Interim Assistance Reimbursement agency.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent an accurate and timely decision on the amount of reimbursement.
We rarely use the information you supply us for any purpose other than for reimbursement
determinations. However, we may use the information for the administration of our programs
including sharing information:
1. To comply with Federal laws requiring the release of information from our records (e.g.,
to the Government Accountability Office and Department of Veterans Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the
integrity and improvement of our programs (e.g., to the Bureau of the Census and to
private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice 60-0103, entitled, Supplemental Security
Income Record and Special Veterans Benefits. Additional information about this and other
system of records notices and our programs is available online at www.socialsecurity.gov or at
your local Social Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State or
local government agencies. We use the information from these programs to establish or verify a
person’s eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget (OMB) control number. We estimate that it will take about
30 minutes to read the instructions, gather the facts, and answer the questions. Send only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.