Sample Title XVI Adverse Action Notice

Current Sample Notice

Current Sample Notice – Notice of Planned Action
Reading Grade Level: 10

Social Security Administration
Supplemental Security Income
Notice of Planned Action

Office of Central Operations
500 Woodlawn Drive
Baltimore, Maryland 21241-1500
Date: April 9, 2020
BNC#
Nancy Drew
123 Detective Lane
Sleuth, MD 21201
As you requested, we will call you within 5 business days of the date of this letter
to read it to you.
We are sending this letter to you in both a standard print version and a large print
version. You will receive them in separate envelopes.
We are returning 2 paystub documents with the standard print version of this
letter.
Your payments (or those of the individual named above) will be changed as
follows:
From
Amount

Through

Monthly Amount

Monthly

March 2020

March 2020

$741.34

$757.06

April 2020

April 2020

$741.34

$670.38

Information About NANCY DREW's Back Payments

We will send you another letter about any overpayment.
Information Used In Making The Decision

You had monthly income which must be considered in figuring his eligibility
as follows:
Your verified wages of $112.88 for January 2020, $286.25 for February
2020 and $185.37 for March 2020.
Things To Remember
If we stop your SSI and close your SSI case you do not become eligible again
before May 2020, you will have to file a new application to get SSI.
Information About Your Payment(s)
We are holding your first payment of $500 for June 2020 because you agreed in
writing that the SSI program would be repaid the money it paid you for May
2020. After that agency tells us how much it should be repaid, we will send it the
money from your first payment. If any money is left from the first payment, we
will send it to you. The SSI Field Office should send you a letter explaining what
you should do if you disagree with the amount they told us to pay them.
If You Disagree With The Decision
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.

• 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.

Appeal In 10 Days To Keep Getting The Same Check
If you appeal within 10 days, you will continue to get the same check amount until
we decide your case.

• The 10 days start the day after you get this letter.

• If you lose your appeal, you might have to pay back some or all of this
money.

However, even if you appeal in 10 days, we may reduce the check in June 2020 as
shown above if both of the following are true:

• 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
check.

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.

If You Want Help With Your Hearing
You may choose to have a representative help you. We will work with this person
just as we would work with you. If you decide to have a representative, you
should find one quickly so that person can start preparing your case.
Many representatives charge a fee only if you receive benefits. Others may
represent you for free. Usually, your representative may not charge a fee unless
we approve it. Your local Social Security office can give you a list of groups that
can help you find a representative.
If you get a representative, you or that person must notify us in writing. You may
use our Form SSA-1696 "Appointment of Representative." Any local Social
Security office can give you this form.

If You Want An Interpreter To Help You
We provide free interpreter services to help you conduct your Social Security
business. These interpreter services are available whether you talk to us by
phone or in the Social Security office. Call our toll-free number, 1-800-772-1213,
press 2 if you need an interpreter in Spanish, and stay on the line until a
representative answers. An interpreter who speaks Spanish will be contacted to
help with your call. If your business cannot be completed by phone, we will
make an appointment for you at a local Social Security office and arrange for an
interpreter to be there at the time of your visit.
Suspect Social Security Fraud?
Please visit http://oig.ssa.gov/r or call the Inspector General's
Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).
If You Have Questions
We invite you to visit our website at www.socialsecurity.gov on the Internet to
find general information about Social Security. If you have any specific
questions, you may call us toll- free at 1-800-772-1213, or call your local Social
Security office at 410-555-1212. We can answer most questions over the phone.
If you are deaf or hard of hearing, you may call our TTY number, 1-800-3250778. You can also write or visit any Social Security office. The office that
serves your area is located at:
123 Main Street
Owing Mills MD 21201
If you do call or visit an office, please have this letter with you. It will help us
answer your questions. Also, if you plan to visit an office, you may call ahead
to make an appointment. This will help us serve you more quickly when you
arrive at the office.
If you plan to visit an office you may call ahead to make an appointment. This
will help us serve you more quickly.
Social Security Administration
Enclosure(s):
How we calculated NANCY DREW’S payment