Work Activity Report--Employee

Sample Notice – Extended Period of Eligibility Cessation

Reading Grade Level 8.6

Social Security Administration

Retirement, Survivors, and Disability Insurance

Notice of Proposed Decision

OFFICE OF CENTRAL OPERATIONS

7-F-15 7TH FLR SW TWR

1500 WOODLAWN DRIVE

BALTIMORE MD 21241

	Date:  September 24, 2011
	BNC#:
M PUBLIC
1234 MAIN ST
BIRMINGHAM, AL xxxxx-xxxx

We reviewed your work record to see if you are still eligible for Social Security disability insurance benefits. We looked at your work and earnings for August 2009 through August 2011. Our review shows that, because of your work, you may not be eligible for disability payments for:

January 2010 through July 2010

Any Medicare coverage you have can continue. We will send you another letter if your Medicare coverage changes.

We have not decided if you can still get disability payments. You can still give us more information about your work. For example, you may give us pay stubs to show when you worked, information about job coaching or vocational rehabilitation services that you received, or receipts for your impairment-related work expenses.

What You Should Do

• Read this letter carefully.

• Contact us within 10 days if you have more information that you want us to consider.

• The 10 days start the day after you receive this letter. We assume that you

got this letter within 5 days after the date on it, unless you show us that you did not get it within the 5-day period.

• Let us know right away if you need more time.

• You may call us toll-free at 1-800-772-1213 or contact your local Social Security office.

If We Do Not Hear From You

If we do not hear from you within 10 days, we will make our decision about your disability payments based on the information we have now. We may decide to suspend your disability payments. We will send you another letter when we make our decision.

The Information We Have

Here is the information we have that affects your disability payments:

• Your signed statement regarding work and earnings

• Our records of your earnings

• Work information reported to us by your employers

• Other

Our records show that you worked the following dates:

Work Started Work Ended Employer

November 2010	Not Ended	DOUGLAS SCOTT POWERS
August 2009	July 2010	HOOVER CITY BOARD OF EDUCATION

We may have used earnings information from our records based on when you were paid to determine when you worked. If our records do not correctly reflect when you worked, you can give us more information.

Our records show that you have the following items that we may deduct from your earnings:

• Impairment-related work expenses: Impairment-related work expenses are certain costs for items or services you need because of your disability to help you work. We can only deduct costs that you pay for yourself. We cannot deduct these costs if another source, such as an insurance plan, will reimburse you. You must submit proof of payment and we must approve your expenses. Some examples of these expenses are medicines, equipment, and counseling or therapy sessions.

Our records show that you do not have the following items that we may deduct from earnings:

• Subsidies and special conditions: Subsidies and special conditions are extra help you receive on the job because of your disability. Some examples of extra help you may receive on the job are extra breaks or a job coach.

• Unincurred business expenses: If you are self-employed, an unincurred business expense is a free item or service to support your business. Some examples are free rent, unpaid help from friends and family members, or donated equipment and supplies.

Your Extended Period of Eligibility

After your trial work period ends, you get an extended period of eligibility that lasts for at least 3 years. During your extended period of eligibility, you may still receive payments depending on how much you work and earn. We pay you disability benefits during this period if:

• your condition is still disabling, and

• your work is not substantial gainful activity.

What Is Substantial Gainful Activity?

Substantial gainful activity is physical or mental work you can do for pay or profit. It can be full-time or part-time work. Generally, we use your earnings amounts to decide if your work is substantial and gainful. If you are self-employed, we may consider what you do in the business to decide if your work is substantial and gainful. Please see the enclosed chart about your extended period of eligibility. It shows your monthly earnings and the earnings amounts we use as guidelines to decide if we count that month as substantial gainful activity.

Substantial Gainful Activity for Persons Who Are Blind

We use different earnings amounts when we decided whether a person who meets our definition of blindness has done substantial gainful activity. The earnings amounts for a person who is blind are higher than the amounts we use for a person who is disabled. We have two ways to determine blindness:

• if you have a central visual acuity of 20/200 or worse in the better eye with the use of a correcting lens and with the best-corrected visual acuity, or

• if you have a visual field limitation in the better eye such that the widest diameter of the visual field subtends an angle of 20 degrees or less.

Contact us if you meet our definition of blindness.

Disability Payments During Your Extended Period of Eligibility

During the first 3 years of your extended period of eligibility, we can pay you disability payments for:

• any month your work is not substantial gainful activity, and

• the first month that your work is substantial gainful activity, and

• the next 2 months no matter how much you earn.

Your extended period of eligibility began January 2009 and it has not ended. It will end if your work is substantial gainful activity after December 2011.

Your first month of substantial gainful activity was January 2010, so we paid you for January 2010, February 2010, and March 2010. We cannot pay you for April 2010 through July 2010 because your work was substantial gainful activity.

Suspect Social Security Fraud?

If you suspect Social Security fraud, please visit http://oig.ssa.gov/report or call the Inspector General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).

If You Have Questions

If you have any questions, please:

• Visit our website at www.socialsecurity.gov to find general information about Social Security;

• Call John Smith at the Office of Central Operations at 1-800-555-5555;

• Call us toll-free at 1-800-772-1213 or call your local office at 555-555-5555.  We can answer most questions over the phone.  If you are deaf or hard of hearing, our toll-free TTY number is 1-800-325-0778; or

• Write or visit any Social Security office.  If you plan to visit an office, you may call ahead to make an appointment.  The office that serves your area is located at:

123 ABC Street

Falls Church, VA 12345

Please have this letter with you if you call or visit an office. If you write, please include a copy of the first page of this letter. It will help us answer your questions.

Social Security Administration

Enclosure(s):

Monthly Work and Earnings – Extended Period of Eligibility

Monthly Work and Earnings – Extended Period of Eligibility

Month Year	Monthly Earnings and/or Self Employment Hours	Amounts We Do Not Count	Monthly Substantial Gainful Activity Amounts	Substantial Gainful Activity Month	Due Benefits?
01/2010	$1320 4 Hours	*IRWE $300	$1000	Yes	Yes
02/2010	$1320 4 Hours		$1000	Yes	Yes
03/2010	$1320 4 Hours		$1000	Yes	Yes
04/2010	$1320 4 Hours		$1000	Yes	No
05/2010	$1314 4 Hours		$1000	Yes	No
06/2010	$1345 4 Hours		$1000	Yes	No
07/2010	$1328 4 Hours		$1000	Yes	No
08/2010	$930 4 Hours		$1000	No	Yes
09/2010	$930 4 Hours		$1000	No	Yes
10/2010	$305 4 Hours		$1000	No	Yes
11/2010	$305 4 Hours		$1000	No	Yes
12/2010	$312 4 Hours		$1000	No	Yes

* Note: IRWE – Impairment Related Work Expense