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

Form SSA-L8125 (07-2020) UF
Discontinue Prior Editions

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OMB No. 0960-0546

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

GR CODE:

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 (IA) 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 payment is made.
• You may recoup the assistance you paid for any month in a period as defined
above for which both SSI and IA payments were made. You may not recoup for
any months prior to the month in which you began paying IA in 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."

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Form SSA-L8125 (07-2020)

• 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 IA
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
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.
See Revised Privacy Act Statement Attached
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.
See Revised PRA Attached
Paperwork Reduction Act - 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.

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Form SSA-L8125 (07-2020)

IAR Payment Pending Case State Due Payment
Priority Handling
Complete & Return Within 10 Working Days:
Claimant Information
Initial Claim

Post-eligibility Claim

Recipient's Name

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 #

GR Code

Amount
1. Amount of interim assistance paid to the individual
Amount
2. Amount of reimbursement claimed by the State
Month/Year
3. First month for which State paid IA 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

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

By

Date

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Form SSA-L8125 (07-2020)

Retroactive Amount Due Summary
Recipient's Name
From

SSN
Through

Amount Each Month

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Form SSA-L8125 (07-2020)

Retroactive Amount Due Summary
Recipient's Name
From

SSN
Through

Amount Each Month

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Form SSA-L8125 (07-2020)

Retroactive Amount Due Summary
Recipient's Name
From

SSN
Through

Amount Each Month