New Jersey Administrative Code › Title 8 - HEALTH › Chapter 133 - INTERIM ASSISTANCE PROCEDURES MANUAL › Appendix I

Current through Register Vol. 56, No. 14, July 15, 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