N.J. Admin. Code § Tit. 8, ch. 133, app I
Current through Register Vol. 56, No. 11, June 3, 2024
| APPENDIX I | ||||
| SOCIAL SECURITY ADMINISTRATION | ||||
| Supplemental Security Income | ||||
| Notice of Interim Assistance Reimbursement | ||||
| Date: _______________________________ | ||||
| Social Security Number: _____________ | ||||
| GR Code: ____________________________ | ||||
| ACTION REQUIRED BY THE STATE | ||||
| Complete the State's Accountability Report using the information in the "PAYMENT SUMMARY." Return all but this page of the notice to the Social Security Administration within 30 days of receipt of the Interim Assistance Reimbursement check. | ||||
| THINGS TO REMEMBER WHEN DETERMINING YOUR AMOUNT OF REIMBURSEMENT | ||||
| . Federally Reimbursable IA is assistance from State or local funds to an individual for meeting basic needs either during the period beginning with the first day for which such individual was eligible for SSI benefits; 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 benefits, and ending with (and including) the month payment is made. | ||||
| . You may recoup interim assistance you paid for any month in a period as defined above. You may not recoup for any months prior to the month for which you began paying interim assistance in this period. If a month is not listed in the "Payment Summary" you cannot recoup the assistance you paid for that month. | ||||
| . In cases where SSI payments were prorated, you must prorate the amount you recover for that month. You cannot recover the difference you paid for a prorated month from any other month. You can determine that a month's payment was prorated if the day is other than the first of the month. | ||||
| . Assistance payments financed in whole or part from Federal funds (e.g., AFDC) 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. | ||||
| SSA-L8125 | ||||
| CLAIMANT INFORMATION | ||||
| Initial Claim | ||||
| Date of SSI Eligibility: | ||||
| Amount of SSI Retroactive Payment: | ||||
| Amount and Month of Recurring SSI Payment: | ||||
| STATE'S ACCOUNTABILITY REPORT | ||||
| AMOUNT | DATE RECEIVED | DATE SENT | ||
| 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 | FIRST MONTH FOR WHICH | NOTE: Total of items 3, 4 | ||
| YOU PAID IA THIS PERIOD | and 5 should equal the amount shown in item 1 | |||
| CERTIFICATION STATEMENT | ||||
| I certify that the above is a true statement of receipts and disbursements | ||||
| under our agreement with the Secretary of Health and Human Services for the | ||||
| purpose of furnishing interim assistance to individuals as established by | ||||
| P.L. 93-368, as amended. | ||||
| _____________________ | _______________________ | ____________________________ | ||
| Signature | Title & Agency | Date | ||
| PAYMENT SUMMARY | ||||
| FROM | THROUGH | AMOUNT PAID EACH MONTH | ||
| SSA-L8125 | ||||
N.J. Admin. Code Tit. 8, ch. 133, app I