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

Form Approved
OMB No. 0960-0546

Social Security Administration
Supplemental Security Income
Notice of Interim Assistance Reirnbursement
Date:

Claim Number:

GRCODE:

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 to:

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. "

Form SSA-LS125-F6 (10-1997) EF (05-2006)

Page 2
•

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.

See Revised Privacy Act Statement, Attached

Privacy Act Notice - The Social Security Administration (SSA) is authorized to collect this
information under §1631 (g) of the Social Security Act. At times, it is required to determine
the amount of interim assistance to reimburse the State before it can release the IAR payment
to the State because of amendments to the Social Security Act such as the recently enacted
large past-due SSI benefits provisions of Public Law 104-193. Failure to provide all or part of
the information could prevent an accurate and timely decision on the amount of
reimbursement. The information you furnish here will not be used for any other purpose.
See Revised PRA Attached

Paperwork Reduction Act Statement - 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
control number. We estimate that it will take about 10 minutes to read the instructions, gather
the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO
YOUR LOCAL SOCIAL SECURITY OFFICE. To rmd the nearest office, call
1-800-772-1213. Send only comments on our time estimate above to: SSA, 6401 Security
Blvd., Baltimore, MD 21235-6401.

Form SSA-LS125-F6 (10-1997) EF (05-2006)

Form Approved
OMB No. 0960'()546

Page 3
IAR PAYMENT PENDING CASE

STATE DUE PAYMENT******PRIORITY HANDLING

COMPLETE & RETURN WITHIN 10 WORKING DAYS:

**************** ******CLAIMANT INFORMATION**********************
Initial Claim _ _ _ _ _ _ _ Posteligibility Claim _ _ _ _ _ _ _ Other
Recipient's Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

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

Date

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

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ By _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___

Form SSA-LS12S-F6(10-1997) EF (05-2006)

Page 4

*************......*... RETROACTlVE AMOUNT DUE SUMMARY*..............................***...**

Recipient's Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Recipient's SSN _ _ _ _ _ _ __

FROM

THROUGH

Form SSA-L812S-F6 (10-1997) EF (05-2006)

AMOUNT EACH MONTH

Page 5

*****************RETROACTIVE AMOUNT DUE SUMMARY*****************
Recipient's Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Recipient's SSN _ _ _ _ _ _ __

FROM

THROUGH

Form SSA-LS125-F6 (10-1997) EF (05-2006)

AMOUNT EACH MONTH

Page 6

*"'''''''*''''''''''''''''''''''''''''''''''''RETROACTIVE AMOUNT DUE SUMMARY"'''''''''''''''''''''''''''''''''''''****
Recipient's Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Recipient's SSN _ _ _ _ _ _ _ __

FROM

THROUGH

Form SSA-L8125-F6 (10-1997) EF (3-2006)

AMOUNT EACH MONTH

GlD'

u.s. GOVERNMENT PRINTING OFFICE: 2008-339·224160213

SSA will insert the following revised Privacy Act Statement into the form at its next
scheduled reprinting:

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. The information you provide will be used to determine the amount of
interim assistance to reimburse the state.
The information you furnish on this form is voluntary. However, failure to provide the
requested information may prevent an accurate and timely decision on the amount of
reimbursement.
We rarely use the information you supply for any purpose other than for determining
reimbursements. However, we may use it for the administration and integrity of Social
Security programs. We may also disclose information to another person or to another
agency in accordance with approved routine uses, which include but are not limited to the
following:
1. To enable a third party or an agency to assist Social Security in establishing
rights to Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and
Department of Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income
maintenance programs at the Federal, state and local level; and
4. To facilitate statistical research, audit or investigative activities necessary to
assure the integrity of Social Security programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, state or local
government agencies. Information from these matching programs can be used to establish
or verify a person’s eligibility for Federally funded or administered benefit programs and
for repayment of payments or delinquent debts under these programs.
Additional information regarding this form, routine uses of information, and our
programs and systems, is available on-line at www.ssa.gov or at your local Social
Security office.

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
Paperwork Reduction Act Statement - 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 control number. We estimate that it will take about 10
minutes to read the instructions, gather the facts, and answer the questions. SEND THE
COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The
office is listed under U. S. Government agencies in your telephone directory or you
may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send
comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD
21235-6401. Send only comments relating to our time estimate to this address, not the
completed form.