Form SSA-8125 Supplemental Security Income Notice of Interim Assistanc

Form Approved
OMB No. 0960·0546

SUPPLEMENTAL SECURITY INCOME NOTICE OF INTERIM

ASSISTANCE REIMBURSEMENT

PART I: STATE AGENCY IDENTIFYING INFORMATION

Date:

TO: (Name and address of State Agency)

GR CODE:

PART II: CLAIMANT INFORMATION

NAME AND ADDRESS: (Includes Representative Payee's Name and Address if applicable)

CLAIM

SOCIAL SECURITY NUMBER

DATE OF SSI ELIGIBILITY

AMOUNT OF SSI RETROACTIVE
PAYMENT

AMOUNT AND MONTH OF RECURRING SSI PAYMENT

PART III: PAYMENT SUMMARY

PART IV: STATE'S ACCOUNTABILITY REPORT

1. Amount of reimbursement check the State received from SSA
2. Amount of interim assistance paid to the individual
3. Amount of the reimbursement check retained by the State
4. Amount of the reimbursement check forwarded to the individual
5. Amount of reimbursement check returned to SSA
DATE NOTICE RECEIVED

MONTH FOR WHICH STATE PAID
A THIS PERIOD

Total of items 3, 4, and 5 should equal the
shown in item 1.

I cenify that the above is a true statement of receipts and disbursements under our agreement with the Commissioner of Social Security for the purpose
of furnishing interim assistance to individual as established by P.L. 93-368, as amended.

S'GNATURE

ITITLE AND AGENCY

Form SSA-8125 (10·1997) Use Until Stock is Exhausted EF 101-2003)

IDATE

.... OVER ...

ACTION REQUIRED BY THE STATE
Complete the State's Accountability Report using the information in the "PAYMENT SUMMARY" and
return to the Social Security Administration within 30 days of receipt of the Interim Assistance
Reimbursement check.
TIllNGS TO REMEMBER WHEN DETERMINING YOUR AMOUNT OF REIMBURSElVIENT
• 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 defmed above for which both
SSI an 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 "Payment 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 that individual's SSI
payment from SSA, you may recoup that assistance payment even though it is not listed in the
"Payment Summary. "
• 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 payment
was prorated if the day is other than the fIrst of the month.
• Assistance payments fmanced in whole or part from Federal funds (e.g., TANF) do not come within
the meaning of interim assistance.
• Excess IAR payments are to be made to the individual within 10 working days of receipt of the
reimbursement check.
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. It is required to determine the amount of interim
assistance to reimburse the State. 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.
Explanations about these and other reasons why information you provide us may be used or given out are
available in Social Security Offices. If you want to learn more about this, contact any Social Security Office.
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 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. You may send comments on our time estimate above to: SSA, 1338 Annex Building,
Baltimore, MD 21235-0001. Send only comments relating to our time estimate to this address, not the
completed form.
Form SSA·8125 (10·1997) EF (01·2003)

G:O

u.s. GOVERNMENT PRINTING OFFICE: 2006-32CHl38/00785

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.