Sample MOU used with IAR Agencies

FINAL—4-2-02
SUPPLEMENTAL SECURITY INCOME FOR THE
AGED, BLIND, AND DISABLED
Agreement for Reimbursement to State
for Interim Assistance Payments
Pursuant to Section 1631(g)
of the Social Security Act
Between
The Commissioner of the Social Security Administration
and
The State of ______
The Commissioner of the Social Security Administration,
hereinafter referred to as the "Commissioner," and the State of
________, hereinafter referred to as the "State," for the purpose
of ensuring the availability of assistance to meet basic needs of
applicants for benefits under the supplemental security income
(SSI) program, title XVI of the Social Security Act, hereby agree
to the following:

ARTICLE I
SCOPE
This Agreement covers reimbursement by the Commissioner to the
State for assistance furnished by the State to individuals during
Unless otherwise noted use all language that follows throughout
this Agreement:
Use the following language if the State elects to be reimbursed
only for initial claims: "the months their SSI applications are
pending. However, a State may be reimbursed only for months
during the periods in which the individual was paid both an SSI
dollar amount payment and an interim assistance (IA) dollar
amount payment."
Use the following language if the State elects to be reimbursed
only for initial posteligibility: "the months their SSI benefits
have been suspended or terminated, if said individuals are
subsequently found to be eligible for payment of SSI benefits for
those months. However, a State may be reimbursed only for months
during the periods in which the individual was paid both an SSI
dollar amount payment and an IA dollar amount payment."

2
"Use the following language if the State elects to be reimbursed
for initial claims and initial posteligibility: "(a.) the months
their SSI applications are pending and (b.) during the months
their SSI benefits have been suspended or terminated, if said
individuals are subsequently found to be eligible for SSI payment
of benefits for those months. However, a State may be reimbursed
only for months during the periods described in (a.) or (b.)
above in which the individual was paid both an SSI dollar amount
payment and an interim assistance (IA) dollar amount payment."
ARTICLE II
DEFINITIONS
For purposes of this Agreement:
A.

The term "Commissioner" means the Commissioner of the Social
Security Administration (SSA) or his/her delegate.

B.

The term "State" for purposes of an IA agreement means a
State of the United States, the District of Columbia, or the
Northern Mariana Islands. For all other purposes (for
example, payment, appeals, notices) State also means an
entity that the Commissioner deems to be a political
subdivision and that such political subdivision is
administratively feasible to include for participation in
the interim assistance reimbursement (IAR) program. The
political subdivision of the State of __________________
administering this IA agreement is the
__________________________________________.

C.

The term "Act" means the Social Security Act.

D.

The term "benefits" means supplemental security income
benefits under title XVI of the Act and any State
supplementary payments under section 1616 thereof, or
mandatory minimum supplementary payments under section 212
of Public Law 93-66, which the Commissioner makes on behalf
of the State (or political subdivision thereof).

E.

Use the following language if the State elects to be
reimbursed only for initial claims: The term "IA" means
assistance furnished to the individual or on behalf of the
individual, financed totally from State and/or local funds,
for meeting basic needs and furnished during the period
beginning with the month following the month in which the
individual filed an application for benefits, for which
he/she was found eligible to receive benefits, and ending
with (and including) the month the individual's benefits

3
began.
Use the following language if the State elects to be
reimbursed only for initial posteligibility: The term "IA"
means assistance furnished to the individual or on behalf of
the individual, financed totally from State and/or local
funds, for meeting basic needs and furnished during the
period beginning with the day the individual's benefits were
reinstated after a period of suspense or termination, and
ending with (and including) the month the individual's
benefits were resumed.
Use the following language if the State elects to be
reimburse for initial claims and initial posteligibility:
The term "interim assistance" (IA) means assistance
furnished to the individual or on behalf of the individual,
financed totally from State and/or local funds, for meeting
basic needs and furnished (1) during the period beginning
with the month following the month in which the individual
filed an application for benefits, for which he/she was
found eligible to receive benefits, and ending with (and
including) the month the individual's benefits began, and
(2) during the period beginning with the day the
individual's benefits were reinstated after a period of
suspense or termination, and ending with (and including) the
month the individual’s benefits were resumed.
F.

Use the following language if the State elects to be
reimbursed only for initial claims: The term "initial
payment" means the first payment with respect to the IA
period discussed in E. above, but does not include any
emergency advance payments authorized under section
1631(a)(4)(A) of the Act, any presumptive
disability/blindness payment authorized under section
1631(a)(4)(B), or any immediate payments authorized under
section 1631(a)(1).
Use the following language if the State elects to be
reimbursed only for initial posteligibility: The term
"initial posteligibility payment" means the first payment
with respect to the IA period discussed in E. above, but
does not include any emergency advance payments authorized
under section 1631(a)(4)(A) of the Act, any presumptive
disability/blindness payment authorized under section
1631(a)(4)(B), or any immediate payments authorized under
section 1631(a)(1).
Use the following language if the State elects to be
reimbursed for initial claims and initial posteligibility:
The terms "initial claims" and " initial posteligibility
payment" mean the first payment with respect to the IA

4
period discussed in E. above, but does not include any
emergency advance payments authorized under section
1631(a)(4)(A) of the Act, any presumptive
disability/blindness payment authorized under section
1631(a)(4)(B), or any immediate payments authorized under
section 1631(a)(1).
G.

The phrase "amount equal to the amount of initial payment
[or initial posteligibility payment] available to the State
as IA reimbursement" means that portion of the initial (or
initial posteligibility) payment that the State can claim as
reimbursement. In certain situations, the Commissioner is
required by the Act to control the release of an
individual’s retroactive payment. In these situations, if
SSA were to release the initial payment or initial
posteligibility to the State and the State released a
residual amount to the individual, the individual might be
paid in a manner contrary to the Act. To prevent this, when
SSA identifies such a situation, SSA will ask the State to
determine the amount it is entitled to be reimbursed, and
SSA will then release that amount to the State.

H.

The term "Supplemental Security Income Program" means the
Federal assistance program under title XVI of the Social
Security Act.

I.

The term "authorization" means the form used by the State to
obtain an SSI applicant's written permission for the
Commissioner to withhold the individual's initial payment or
initial posteligibility payment and send such payment to the
State. This form must include the language specified in
Article IV, Paragraph A and be approved by the State and
Commissioner.

J.

The term "protective filing" means a written Statement by an
individual indicating an intent to claim SSI benefits
received at an SSA office or another Federal or State office
designated by the Commissioner to receive applications on
behalf of the Commissioner, or by a person so authorized.
For purposes of this Agreement, the term protective filing
is limited to the written authorization defined in Article
II, Paragraph I.

5
ARTICLE III
FUNCTIONS TO BE PERFORMED BY THE COMMISSIONER
The Commissioner shall:
A.

Send to the State or the State's designated financial
institution (when feasible for both parties) the initial
payment [if initial posteligibility is applicable, include
the following: "initial posteligibility payment"](or "an
amount equal to the amount of initial payment [or initial
posteligibility payment] available to the State as IA
reimbursement" as defined in Article II, paragraphs F. and
G., in situations where the Commissioner is required to
control the release of the individual’s retroactive payment)
for any such individual for whom a signed copy of an
authorization, as defined in Article II, Paragraph I., has
been received by the Commissioner, or by a Federal or State
office designated by the Commissioner to receive
applications, prior to the date of payment.

B.

Provide information to the State in order to assist the
State in complying with the terms of the Agreement.

C.

Perform such other functions as may be required by the terms
of this Agreement.

ARTICLE IV
FUNCTIONS TO BE PERFORMED BY THE STATE
The State shall:
A.

For political subdivisions of a State that the Commissioner
deems to be administratively feasible to include for
participation in the IAR program based on scope and size,
obtain a written, signed, and dated authorization for the
reimbursement of IA (models attached hereto at Appendix A),
for each individual who has received or will receive IA, and
whose initial payment [if initial posteligibility is
applicable, include the following: "or initial
posteligibility payment"] or "amount equal to the amount of
the initial payment [and/or initial posteligibility payment]
available to the State as IA is to be sent to the State or
the State's designated financial institution pursuant to
Article III, Paragraph A and (in the case of a manual State)

6
furnish a copy of the authorization or notify the
Commissioner of the receipt and date of receipt of the
authorization (in the case of an automated State). The
authorization form must, at a minimum, provide language that
advises the individual that:
Use the following language if the State elects to be reimbursed
only for initial claims:
1.

For initial SSI claims, the period for the life of the
authorization is one (1) calendar year if the
individual does not apply for SSI within the one-year
period. The one year period begins with the date SSA
receives the signed authorization (in the case of a
manual State) or the date that the State notifies SSA
by an automated system that it has received a signed
authorization (in the case of an automated State) and
ends one calendar year later. In addition, if the
State does not notify the Commissioner within thirty
(30) calendar days of the date the individual signed
the authorization, the authorization is not binding on
the applicant. (This condition is intended to assure
that the State acts on the authorization in a
reasonably prompt manner.). However, if the individual
applies for SSI before the end of the one year life of
the authorization period or has already applied for SSI
before the period for the life of the authorization
begins, the period for the life of the authorization
will be extended beyond the one year period, until such
time as:
-

The Commissioner makes the first payment of SSI
retroactive benefits on the individual's claim; or

-

The Commissioner makes a final determination on
the claim and no timely request for review is
filed; or

-

The State and the individual agree to terminate
the authorization.

If one of the events listed above occurs before the
expiration of the one-year calendar period, the
authorization will cease to be in force as of the date
of the occurrence of such an event.
2.

After deducting from the individual's initial payment
received from the Commissioner an amount sufficient to
reimburse the State for IA paid the individual, the
State shall promptly provide to the individual a
written notice (copy attached hereto at Appendix B)

7
explaining the amount of the initial payment it
received from the Commissioner and the excess amount
(if any) due the individual and shall pay the excess
amount (if any) to such individual within ten (10)
working days of the receipt of said payment from the
Commissioner.
3.

The State shall complete and return an SSA accounting
form to a designated SSA office within 30 calendar days
of the date SSA forwarded or transmitted such form to
the State. However, for situations in which the
Commissioner is required by law to restrict the manner
in which the residual amount of retroactive SSI
payments may be paid to the individual, the State shall
complete and return the SSA accounting form to a
designated SSA office within 10 working days of the
date SSA forwarded or transmitted the form to the
State. If a State does not forward or transmit the
accounting form to SSA within 10 working days of the
date it was forwarded or transmitted to the State, SSA
will forward or transmit to the State a follow-up
request for the completion and return of that form. If
a State fails to return the form to the designated SSA
office within 15 working days of the follow-up request,
SSA will release the retroactive amount to the
individual through its applicable processing procedures
to protect the individual from hardship that may arise
from the State’s failure to comply with SSA’s IAR
processing requirements. In these situations, the
State may choose to ask the individual for any IAR the
State may be due. However, the Commissioner will not
be a party to or responsible for participating in the
State's efforts to recover any IAR due the State under
these circumstances.

4.

Such individual shall have the right to a hearing from
the State respecting any matter for which the
individual believes he or she has been aggrieved by
action taken by the State under section 1631(g) of the
Act."

B.

The State may receive on the Commissioner's behalf, the
authorization as an intent by the individual to claim SSI
benefits (a protective filing) for all political
subdivisions within the State as identified in appendix C of
this Agreement.

C.

Political subdivisions of the State listed in Appendix C
that use a manual process will forward the authorizations to
the Commissioner within thirty (30) calendar days of
obtaining the authorizations and shall retain copies of such

8
authorizations in accordance with the provisions of Article
VIII.
D.

Political subdivisions of the State listed in Appendix D
that use an automated process will forward via an automated
data processing method acceptable both to the Commissioner
and the State information: (1) that the State has received
such authorization and (2) the date that the State and the
claimant signed the authorization. This information will be
forwarded to the Commissioner within thirty (30) calendar
days of matching the applicant's record on the State's
general assistance eligibility file with a pending SSI
record and the State shall retain copies of such
authorizations in accordance with the provisions of Article
VIII.

E.

For situations in which the Commissioner is not required by
law to restrict the manner in which the residual amount of
retroactive SSI payments may be paid to the individual:

F.

1.

Deduct from the initial payment received from the
Commissioner, with respect to an individual, an amount
sufficient as reimbursement for IA furnished on behalf
of such individual in months during which the
individual was found eligible for SSI, from the first
month in which such individual was found to be eligible
for SSI benefits, and ending with and including the
month payment of such individual's SSI benefits began.

2.

Pay any residual amount of the initial payment received
from the Commissioner to the individual within 10
working days from the date the State receives the
initial payment.

For situations in which the Commissioner is required by law
to restrict the manner in which the residual amount of
retroactive SSI payments may be paid to the individual:
Inform the Commissioner, according to Article V,
Paragraph B, of the amount of reimbursement claimed for
IA the State furnished on behalf of such individual in
months during which the individual was found eligible
for SSI, from the first month in which such individual
was found to be eligible for SSI benefits, and ending
with and including the month payment of such
individual's SSI benefits began.

9
G.

Provide to the individual within ten (10) working days of
the date that the State receives the initial payment a
written notice explaining:
1.

The amount of the payment received from the
Commissioner for IA:

2.

The excess amount (if any) due the individual; and

3.

The opportunity for a hearing with respect to any
action taken by the State pursuant to the
implementation of this Agreement by which the
individual believes he or she has been aggrieved.

If an individual dies after executing an authorization but
before receiving the written notice and payment of the
excess amount required by the preceding sentence, the State
shall, within the prescribed time limit, provide such
explanation and pay such balance to the Commissioner rather
than to anyone else on behalf of the individual.
H.

Comply with such other rules as the Commissioner finds
necessary to achieve efficient and effective administration
of IAR procedures and to carry out the purposes of the SSI
program.

I.

Perform such other functions as may be required by the terms
of this Agreement.

Use the following language if the State elects to receive
reimbursement only for initial posteligibility cases:
1.

For initial posteligibility cases, the period for the
life of the authorization is one (1) calendar year.
The one year period begins with the date SSA receives
the signed authorization (in the case of a manual
State) or the date that the State notifies SSA by an
automated system that it has received a signed
authorization (in the case of an automated State) and
ends one calendar year later. In addition, if the
State does not notify the Commissioner within thirty
(30) calendar days of the date the individual signed
the authorization, the authorization is not binding on
the applicant. (This condition is intended to assure
that the State acts on the authorization in a
reasonably prompt manner.). The life of the
authorization will remain in effect for that one year
period, or until the end of the maximum period

10
permitted under regulations at Subpart N of 20 CFR
416 within which to request administrative or judicial
review of the Commissioner's determination to suspend
or terminate the individual's SSI benefits, whichever
period of time is longer, unless the individual files a
request within the time for such review, or one of the
following events occurs earlier, in which case the
Authorization will cease to have effect as of the date
of such event:
-

The Commissioner makes the first posteligibility
payment of retroactive SSI benefits following the
suspension or termination of the individual's
benefits; or

-

The Commissioner makes a final determination on
the claim and no timely request for review is
filed; or

-

The State and the individual agree to terminate
the authorization.

If one of the events listed above occurs before the
expiration of the one-year calendar period, the
authorization will cease to be in force as of the date
of the occurrence of such an event.
2.

After deducting from the individual's payment received
from the Commissioner an amount sufficient to reimburse
the State for IA paid the individual, the State shall
promptly provide to the individual a written notice
(copy attached hereto at Appendix B) explaining the
amount of the initial posteligibility payment it
received from the Commissioner and the excess amount
(if any) due the individual and shall pay the excess
amount (if any) to such individual within ten (10)
working days from the date it received said payment
from the Commissioner.

3.

The State shall complete and return the SSA accounting
form to a designated SSA office within 30 calendar days
of the date SSA forwarded or transmitted the form to
the State. However, for situations in which the
Commissioner is required by law to restrict the manner
in which the residual amount of retroactive SSI
payments may be paid to the individual, the State shall
complete and return the SSA accounting form to a
designated SSA office within 10 working days of the
date SSA forwarded or transmitted the form to the
State. If a State does not forward the accounting form
to SSA within 10 working days of the date it was

11
forwarded to the State, SSA will forward the State a
follow-up request for the completion and return of that
form. If a State fails to return the form to the
designated SSA office within 15 working days of the
follow-up request, SSA will release the retroactive
amount to the individual through its applicable
processing procedures to protect the individual from
hardship that may arise from the State’s failure to
comply with SSA’s IAR processing requirements. In
these situations, the State may choose to ask the
individual for any IAR the State may be due. However,
the Commissioner will not be a party to or responsible
for participating in the State's efforts to recover any
IAR due the State under these circumstances.
4.

Such individual shall have the right to a hearing from
the State respecting any matter for which the
individual believes he or she has been aggrieved by
action taken by the State under section 1631(g) of the
Act.

B.

Political subdivisions of the State listed in Appendix C
that use a manual process will forward the authorizations to
the Commissioner within thirty (30) calendar days of
obtaining the authorizations and shall retain copies of such
authorizations in accordance with the provisions of Article
VIII.

C.

Political subdivisions of the State listed in Appendix D
that use an automated process will forward via an automated
data processing method acceptable both to the Commissioner
and the State information: (1) that the State has received
such authorization and (2) the date that the State and the
claimant signed the authorization. This information will be
forwarded to the Commissioner within thirty (30) calendar
days of matching the applicant's record on the State's
general assistance eligibility file with a pending SSI
record and the State shall retain copies of such
authorizations in accordance with the provisions of Article
VIII.

D.

For situations in which the Commissioner is not required by
law to restrict the manner in which the residual amount of
retroactive SSI payments may be paid to the individual:
1.

Deduct from the initial posteligibility payment
received from the Commissioner, with respect to an
individual, an amount sufficient as reimbursement for
IA furnished on behalf of such individual in months
during which the individual was found eligible for SSI,
from the day of the month such individual's payment of

12
SSI benefits were subsequently reinstated after a
period of suspense or termination, and ending with and
including the month such individual's SSI benefits were
resumed.
2.
E.

Pay any residual amount of the payment received from
the Commissioner to the individual.

For situations in which the Commissioner is required by law
to restrict the manner in which the residual amount of
retroactive SSI payments may be paid to the individual:
Inform the Commissioner, according to Article V,
Paragraph B, of the amount of reimbursement claimed for
IA the State furnished on behalf of such individual in
months during which the individual was found eligible
for SSI, from the day of the month such individual's
SSI benefits were subsequently reinstated after a
period of suspense or termination, and ending with and
including the month such individual's SSI benefits were
resumed.

F.

Provide to the individual within ten (10) working days from
the date the State receives the initial posteligibility
payment a written notice explaining:
1.

The amount of the initial posteligibility payment
received from the Commissioner for IA:

2.

The excess amount (if any) due the individual; and

3.

The opportunity for a hearing with respect to any
action taken by the State pursuant to the
implementation of this Agreement by which the
individual believes he or she has been aggrieved.

If an individual dies after executing an authorization but
before receiving the written notice and payment of the
excess amount required by the preceding sentence, the State
shall, within the prescribed time limit, provide such
explanation and pay such balance to the Commissioner rather
than to anyone else on behalf of the individual.
G.

Comply with such other rules as the Commissioner finds
necessary to achieve efficient and effective administration
of IAR procedures and to carry out the purposes of the SSI
program.

H.

Perform such other functions as may be required by the terms
of this Agreement.

13

Use the following language if the State elects to receive
reimbursement for initial claims and initial posteligibility:
1.

For initial SSI claims, the period for the life of the
authorization is one (1) calendar year if the
individual does not apply for SSI within the one year
period. The one year period begins with the date SSA
receives the signed authorization (in the case of a
manual State) or the date that the State notifies SSA
by an automated system that it has received a signed
authorization (in the case of an automated State) and
ends one calendar year later. In addition, if the
State does not notify the Commissioner within thirty
(30) calendar days of the date the individual signed
the authorization, the authorization is not binding on
the applicant. (This condition is intended to assure
that the State acts on the authorization in a
reasonably prompt manner.) However, if the individual
applies for SSI before the end of the one year life of
the authorization period or has already applied for SSI
before the period for the life of the authorization
begins, the period for the life of the authorization
will be extended beyond the one year period, until such
time as:
-

The Commissioner makes the first payment of
retroactive SSI benefits on the individual's
claim; or

-

The Commissioner makes a final determination on
the claim and no timely request for review is
filed; or

-

The State and the individual agree to terminate
the authorization.

If one of the events listed above occurs before the
expiration of the one-year calendar period, the
authorization will cease to be in force as of the date
of the occurrence of such an event.
2.

For initial posteligibility cases, the period for the
life of the authorization is one (1) calendar year.
The one year period begins with the date SSA receives
the signed authorization (in the case of a manual
State) or the date that the State notifies SSA by an
automated system that it has received a signed
authorization (in the case of an automated State) and

14
ends one calendar year later. In addition, if the
State does not notify the Commissioner within thirty
(30) calendar days of the date the individual signed
the authorization, the authorization is not binding on
the applicant. (This condition is intended to assure
that the State acts on the authorization in a
reasonably prompt manner.). The life of the
authorization will remain in effect for that one year
period, or until the end of the maximum period
permitted under regulations at Subpart N of 20 CFR 416
within which to request administrative or judicial
review of the Commissioner's determination to suspend
or terminate the individual's SSI benefits, whichever
period of time is longer, unless the individual files a
request within the time for such review, or one of the
following events occurs earlier, in which case the
authorization will cease to have effect as of the date
of such event:
-

The Commissioner makes the first posteligibility
payment of retroactive SSI benefits following the
suspension or termination of the individual's
benefits; or

-

The Commissioner makes a final determination on
the claim and no timely request for review is
filed; or

-

The State and the individual agree to terminate
the authorization.

If one of the events listed above occurs before the
expiration of the one-year calendar period, the
authorization will cease to be in force as of the date
of the occurrence of such event.
3.

After deducting from the individual's initial payment
or payment received from the Commissioner an amount
sufficient to reimburse the State for IA paid the
individual, the State shall promptly provide to the
individual a written notice (copy attached hereto at
Appendix B) explaining the amount of the initial
payment or payment it received from the Commissioner
and the excess amount (if any) due the
individual and shall pay the excess amount (if any) to
such individual within ten (10) working days of the
date of the receipt of said payment from the
Commissioner.

4.

The State shall complete and return an SSA accounting
form to a designated SSA office within 30 calendar days

15
of the date SSA forwarded such form to the State.
However, for situations in which the Commissioner is
required by law to restrict the manner in which the
residual amount of retroactive SSI payments may be paid
to the individual, the State shall complete and return
the SSA accounting form to a designated SSA office
within 10 working days of the date SSA forwarded the
form to the State. If a State does not forward the
accounting form to SSA within 10 working days of the
date it was forwarded or transmitted to the State, SSA
will forward the State a follow-up request for the
completion and return of that form. If a State fails
to return the form to the designated SSA office within
15 working days of the follow-up request, SSA will
release the retroactive amount to the individual
through its applicable processing procedures to protect
the individual from hardship that may arise from the
State’s failure to comply with SSA’s IAR processing
requirements. In these situations, the State may
choose to ask the individual for any IAR the State may
be due. However, the Commissioner will not be a party
to or responsible for participating in the State's
efforts to recover any IAR due the State under these
circumstances.
5.

Such individual shall have the right to a hearing from
the State respecting any matter for which the
individual believes he or she has been aggrieved by
action taken by the State under section 1631(g) of the
Act."

B.

The State may receive on the Commissioner's behalf, the
authorization as an intent by the individual to claim SSI
benefits (a protective filing) for all political
subdivisions within the State as identified in appendix C of
this Agreement.

C.

Political subdivisions of the State listed in Appendix C
that use a manual process will forward the authorizations to
the Commissioner within thirty (30) calendar days of
obtaining the authorizations and shall retain copies of such
authorizations in accordance with the provisions of Article
VIII.

D.

Political subdivisions of the State listed in Appendix D
that use an automated process will forward via an automated
data processing method acceptable both to the Commissioner
and the State information: (1) that the State has received
such authorization and (2) the date that the State and the
claimant signed the authorization. This information will be
forwarded to the Commissioner within thirty (30) calendar

16
days of matching the applicant's record on the State's
general assistance eligibility file with a pending SSI
record and the State shall retain copies of such
authorizations in accordance with the provisions of Article
VIII.
E.

F.

For situations in which the Commissioner is not required by
law to restrict the manner in which the residual amount of
retroactive SSI payments may be paid to the individual:
1.

Deduct from the initial payment or posteligibilty
payment received from the Commissioner, with respect to
an individual, an amount sufficient as reimbursement
for IA furnished on behalf of such individual in months
during which the individual was found eligible for SSI,
from the first month in which such individual was found
eligible for SSI benefits, and ending with and
including the month payment of such individual's SSI
benefits began [if posteligibility is applicable,
include the following", and/or from the day of the
month such individual's payment of SSI benefits were
subsequently reinstated after a period of suspense or
termination, and ending with and including the month
such individual's SSI benefits were resumed"].

2.

Pay any residual amount of the initial payment or
initial posteligibility payment received from the
Commissioner to the individual within ten (10) working
days from the date the State receives the initial
payment or initial posteligibility payment.

For situations in which the Commissioner is required by law
to restrict the manner in which the residual amount of
retroactive SSI payments may be paid to the individual:
Inform the Commissioner, according to Article V,
Paragraph B, of the amount of reimbursement claimed for
IA the State furnished on behalf of such individual in
months during which the individual was found eligible
for SSI, from the first month in which such individual
was found eligible for SSI benefits, and ending with
and including the month payment of such individual's
SSI benefits began, [if posteligibility is applicable,
include the following", and/or from the day of the
month such individual's payment of SSI benefits were
subsequently reinstated after a period of suspense or
termination, and ending with and including the month
such individual's SSI benefits were resumed"]

17
G.

Provide to the individual within ten (10) working days from
the date the State receives the initial payment or initial
posteligibility payment a written notice explaining:
1.

The amount of the initial payment [if posteligibility
is applicable, include the following: "or initial
posteligibility payment"] received from the
Commissioner for IA;

2.

The excess amount (if any) due the individual; and

3.

The opportunity for a hearing with respect to any
action taken by the State pursuant to the
implementation of this Agreement by which the
individual believes he or she has been aggrieved.

If an individual dies after executing an authorization but
before receiving the written notice and payment of the
excess amount required by the preceding sentence, the State
shall, within the prescribed time limit, provide such
explanation and pay such balance to the Commissioner rather
than to anyone else on behalf of the individual.
H.

Comply with such other rules as the Commissioner finds
necessary to achieve efficient and effective administration
of IAR procedures and to carry out the purposes of the SSI
program.

I.

Perform such other functions as may be required by the terms
of this Agreement.

ARTICLE V
ACCOUNTING REPORTS
A.

For situations in which the Commissioner is not required by
law to restrict the manner in which the residual amount of
retroactive SSI payments may be paid to the individual:
1.

The State shall submit a report on Form SSA-8125 or
other SSA approved accounting form for each initial
payment [if initial posteligibility is applicable,
include the following:" and posteligibility payment"]
received from the Commissioner within thirty (30)
calendar days from the date the State received such
payment.

18

2.

B.

C.

The report shall account to the Commissioner (on an
individual case basis) for the total IA paid, the total
amount of the initial payment (if initial
posteligibility is applicable, include the following:
"or posteligibility payment") received by the State
(for such individual), the amount retained by the State
as reimbursement, the amount (if any) due the
individual, and the date said amount (if any) was sent
to the individual.

For situations in which the Commissioner is required by law
to restrict the manner in which the residual amount of
retroactive SSI payments may be paid to the individual:
1.

The State shall submit a claim on Form SSA-8125-F6 or
other SSA approved accounting form for each report of a
pending initial payment [if initial posteligibility is
applicable, include the following: "and posteligibility
payment"] received from the Commissioner within ten
(10) working days from the date the State receives such
report.

2.

The report shall account to the Commissioner (on an
individual case basis) for the total IA paid to the
individual and the amount of reimbursement claimed by
the State for IA furnished on behalf of such individual
in months for which the individual was found eligible
to receive SSI [if initial posteligibility is
applicable, include the following: "or SSI benefits
were subsequently reinstated after a period of suspense
or termination"].

The aggregate of all reports referred to in Paragraphs A.
and B. above received by the Commissioner in each fiscal
year shall constitute the State's report for such fiscal
year.
ARTICLE VI
RESOLUTION OF DISPUTES

A.

If SSA and the State are unable to agree on any item in
dispute arising under this Agreement, the State may request
the Commissioner of Social Security to make a determination.
Within 90 days from the receipt of such request, the
Commissioner of Social Security, or his/her designee, shall
make a determination in writing with a full explanation

19
thereof, or provide written notification of the reason
such determination cannot be made, what further information
or action by the parties may be required, and within what
time period a determination is expected to be made. This
determination shall be final and conclusive. Pending the
decision of the Commissioner, the State and the Commissioner
shall proceed diligently with performance of this Agreement.
B.

Nothing in this Agreement shall be construed to waive the
State's right to seek judicial review by a court of
competent jurisdiction of both findings of fact and
conclusion of law contained in the Commissioner's decision,
or to enforce its rights under this Agreement by any
available remedy. Nothing in this Agreement shall be
construed as waiving the Commissioner's rights to assert
lack of jurisdiction with respect to any suit brought under
this Agreement, or to enforce the Commissioner's rights
under this Agreement by available remedies.

ARTICLE VII
ADMINISTRATIVE COSTS
Neither the State nor the Commissioner, in performing their
functions and duties under this Agreement, shall pay to the
other, any costs of administration incurred by the other.

ARTICLE VIII
EXAMINATION AND RETENTION OF RECORDS
A.

The State agrees that the Commissioner and the Comptroller
General of the United States (including their duly
authorized representatives) have access to and the right to
examine any pertinent books, documents, papers, and records
of the State for purposes of verifying transactions with
respect to matters covered by this Agreement.

B.

The State shall retain each authorization it receives (or a
copy thereof) for a total of three (3) years from the date
said authorization is signed and for such longer period as
is required for completion or resolution of the audits,
litigation, or other actions involving such records of which
the State has actual notice and which are commenced before

20
the end of the three (3) year period.
C.

The State shall retain a copy of each Form SSA-8125, SSA8125-F6, or other SSA approved accounting form it completes
for three (3) years from the end of the Federal fiscal year
for which the form pertains.

D.

The State shall retain a copy of each written notice
furnished to an individual as set forth in Article IV,
Paragraph G. for three (3) years from the end of the Federal
fiscal year for which the notice pertains.

ARTICLE IX
CONFIDENTIAL NATURE AND LIMITATION
ON USE OF INFORMATION AND RECORDS
A.

The purpose of this Article is to set forth the procedures
for safeguarding the confidentiality of IAR data exchanged
between the Commissioner and the State, and imposing
limitations on the use of that data. IAR data includes the
authorization form as defined in Article II, Paragraph I.;
the automated data that the State transmits or sends to the
Commissioner pursuant to Article IV, Paragraphs C. and D.;
the notice provided to individuals pursuant to Article IV,
Paragraph G.; the Form SSA-8125, SSA-8125-F6, or other SSA
approved accounting form completed by the State pursuant to
Article V.; and any other information provided to the State
by the Commissioner pursuant to Article III, Paragraph B.

B.

The Commissioner will adopt policies and procedures to
ensure that it will use the IAR data obtained from the State
under this Agreement only for purposes of carrying out this
Agreement and will disclose such data only as permitted by
Federal law (e.g., 42 U.S.C. subsection 1306(a), 5 U.S.C.
subsections 552 and 552a, and implementing regulations 20
CFR Part 401).

C.

The State will adopt policies and procedures to ensure that
it will use the IAR data obtained from the Commissioner
under this Agreement only for purposes of carrying out this
Agreement and will disclose such data for other purposes
only with the prior approval of the Commissioner.

D.

The following minimum safeguards will be afforded by the
Commissioner and the State to IAR data exchanged under this

21
Agreement:

E.

1.

Access to the data will be restricted to only those
authorized employees and officials who need it to
perform their official duties in connection with the
intended use of the data;

2.

The data will be stored in an area that is physically
safe from access by unauthorized persons during duty
hours as well as nonduty hours or when not in use;

3.

The data will be processed under the immediate
supervision and control of authorized personnel in a
manner which will protect the confidentiality of the
data, and in such a way that unauthorized persons
cannot retrieve the data by means of computer, remote
terminal or other means; and

4.

All personnel who will have access to the data will be
advised of the confidential nature of the information,
the safeguards required to protect the information and
the sanctions for noncompliance with those safeguards
contained in the applicable Federal and State statutes.

In addition, the Commissioner reserves the right to make
onsite inspections or to make other provisions to ensure
that adequate safeguards are being maintained.

ARTICLE X
TERMS OF AGREEMENT
This Agreement shall begin on ___________ and will be
automatically renewed for successive periods of one (1) year
thereafter (commencing on October lst of each such year), unless
the State or the Commissioner gives written notice not to renew
at least thirty (30) days before the end of the then current
period.

22
ARTICLE XI
TERMINATION AND MODIFICATION OF AGREEMENT
A.

The State or the Commissioner may terminate this Agreement
at any time upon thirty (30) days written notice to the
other party.

B.

This Agreement may be modified in writing at any time by
mutual consent of the parties hereto.

C.

If this Agreement is terminated in any manner (including
nonrenewal), the accounting requirements described in
Article V shall continue to apply for all initial payments
(if initial posteligibility is applicable, include the
following: "and posteligibility payments") received by the
State from the Commissioner prior to such termination.

D.

If this Agreement is terminated by either party, the
Commissioner and the State agree that all cases for which
the State has obtained an authorization as required by
Article IV, Paragraph A., shall be processed in accordance
with the provisions of this Agreement.

23
In Witness whereof, the parties hereby execute this Agreement
this __________________ day of ________________ 1999.

COMMISSIONER OF
SOCIAL SECURITY
BY:_________________
_________________
_________________
_________________
(TITLE)
State OF ___________
BY:_________________
_________________
_________________
_________________

I,_____________________, certify that I am the Attorney General*
of the State of _________; that ____________________
who signed this Agreement on behalf of the State was then the
______________________________ of said State; and that he/she is
authorized to enter into agreements of this nature on behalf of
the State and that there is authority under the laws of the State
of _____________ to carry out all the functions to be performed
by the State as provided herein and comply with the terms of this
Agreement.

______________________________Signature of Counsel
*Or legal counsel for the State Agency

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APPENDICES

Appendix A - State Authorization Form(s)
(Provided by the State)

Appendix B - State Apportionment Notice Form
(Provided by the State)

Appendix C -List of Political Subdivision(s) Using Manual
IAR Process
(Provided by the State)

Appendix D - List of Political Subdivision(s) Using
Automated Process
(Provided by the State)

Appendix E - State Payee and Mailing Address
(Provided by the State)