Waiver of Supplemental Security Income Payment Continuation

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Social Security Administration
Supplemental Security Income
Notice of Planned Action

John Doe
123 Address
Anytown, MD 20001

Social Security
0123 Roadway
Anytown, MD 20000
November 14, 2020
BNC: XXAXXXXAXXXXX

Dear Mr. Doe:
The SSI Payment Will Be Changed – If You Disagree With This Change, Appeal As Soon
As Possible To Keep Getting The Same Payment
We plan to lower your monthly Supplemental Security Income (SSI) payment from $600.00 to
$0.00 beginning December 2020. The amount will change because you have countable resources
worth more than $2,000.
We are also changing the amounts you were due for October 2020 through November 2020.
Your amounts changed because you had countable resources worth more than $2,000.
From

Through

Previous
Monthly Amount

October 2020

November 2020

$600.00

Corrected
Monthly Amount
$0.00

Information About Your Back Payments
We may be in touch with you later about any payments we previously made.
If You Disagree
If you disagree with the decision, you have the right to appeal. We will review your case again
and consider any new facts you have. A person who did not make the first decision will decide
your case.
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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 if you wait more than 60 days 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.

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If You Want To Appeal And Keep Getting The Same Payment, Appeal As Soon As
Possible
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If you appeal within 10 days, your payment amount will not change until we decide your
appeal. The 10 days start the day after you get this letter.
If you appeal after 10 days, but within 60 days, your payment may be reduced
temporarily. We will restart the previous payment amount once we receive and enter the
appeal. You will get the same payment amount until we decide your appeal. The 60 days
start the day after you get this letter.
If you do not want to keep getting the same payment amount while we decide your
appeal, you will need to complete a form called the SSA-263. The form is available at
www.ssa.gov/forms/ online. You should submit the form to us along with the appeal only
if you do not want to keep getting the same payment amount while we decide your
appeal.
If you lose your appeal, you might have to pay back some or all of this money.

However, even if you appeal, we may reduce the payment shown above if both of the following
are true:
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Our new decision is the same as the one you appealed, and
We send or give you a letter with our new decision in time to reduce the payment for July
2021.

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 the 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.

•

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 us 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 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.
Social Security
0123 Roadway
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Anytown, MD 20000

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