Sample Title II Adverse Action Notice

Current Sample Notice – Extended Period of Eligibility Cessation
Reading Grade Level: 10

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

Our records show that you worked the following dates:
Work Started

Work Ended

November 2010
August 2009

Not Ended
July 2010

Employer
DOUGLAS SCOTT POWERS
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 1-866-5012101).
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 555-5555555. 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
01/2010
02/2010
03/2010
04/2010
05/2010
06/2010
07/2010
08/2010
09/2010
10/2010
11/2010
12/2010

Monthly
Earnings
and/or
Self
Employment
Hours
$1320
4 Hours
$1320
4 Hours
$1320
4 Hours
$1320
4 Hours
$1314
4 Hours
$1345
4 Hours
$1328
4 Hours
$930
4 Hours
$930
4 Hours
$305
4 Hours
$305
4 Hours
$312
4 Hours

Amounts
We Do Not
Count

Monthly
Substantial
Gainful
Activity
Amounts

Substantial
Gainful
Activity
Month

Due
Benefits?

*IRWE $300

$1000

Yes

Yes

$1000

Yes

Yes

$1000

Yes

Yes

$1000

Yes

No

$1000

Yes

No

$1000

Yes

No

$1000

Yes

No

$1000

No

Yes

$1000

No

Yes

$1000

No

Yes

$1000

No

Yes

$1000

No

Yes

* Note: IRWE – Impairment Related Work Expense