320.1.
|
GENERAL DESCRIPTION OF EARNINGS REQUIREMENT
A person whose disability began before age 24 meets the earnings requirement of the
law if Social Security credits have been earned for 6 calendar quarters (1 1/2 years)
of work during the 12 quarter (3 year) period ending with a quarter before age 24
in which the disability exists. A person whose disability began between the ages 24
and 31 meets the earnings requirement if Social Security credits have been earned
for work in at least
one-half of the calendar quarters in the period beginning with the calendar quarter
after age 21 and ending with a quarter before age 31 in which the disability exists.
A person whose disability began at age 31 or later needs to meet two provisions of
the earnings requirement: (1) The person needs credit for 20 calendar quarters (5
years) of work during a 40 quarter period (10 years) ending in or after a quarter
in which disability exists, and (2) The person needs credit for one calendar quarter
of work for each year after 1950 (or after reaching age 21, if that is later) up to
the year the disability began. In this second instance, the credits do not have to
have been earned during the past 10 years.
|
320.2.
|
DESCRIPTION OF 6/12 TEST — DISABILITY BEFORE AGE 24
A person whose disability began before age 24 meets the earnings requirement if Social
Security credits have been earned for 6 calendar quarters (1 1/2 years) of work during
the 12 quarter (3 year) period ending with a quarter before age 24 in which the disability
exists.
|
320.3
|
DESCRIPTION OF EARNINGS REQUIREMENT — DISABILITY BETWEEN THE AGES 24-31
A person whose disability began between the ages 24 and 31 meets the earnings requirement
if Social Security credits have been earned for work in at least one-half of the calendar
quarters in the period beginning with the calendar quarter after age 21 and ending
with a quarter before age 31 in which the disability exists.
|
320.4.
|
DESCRIPTION OF EARNINGS REQUIREMENT — DISABILITY AT AGE 31 OR LATER — NOT DUE TO STATUTORY
BLINDNESS
A person whose disability began at age 31 or later needs to meet two provisions of
the earnings requirement: (1) the person needs credit for 20 calendar quarters (5
years) of work during a 40 quarter period (10 years) ending in or after a quarter
in which disability exists, and (2) the person needs credit for one calendar quarter
of work for each year after 1950 (or after reaching age 21, if that is later) up to
the year the disability began. In this second instance, the credits do not have to
have been earned during the past 10 years.
|
320.5.
|
DESCRIPTION OF FULLY INSURED TEST — DISABILITY DUE TO STATUTORY BLINDNESS
A person whose disability is due to statutory blindness meets the earnings requirement
of the law if one Social Security credit has been earned for each year elapsing after
1950 (or after age 21, if that is later) up to the year the person became blind. A
minimum of 6 credits is needed. The credits may have been earned at any time up to
the established date of onset.
|
320.6.
|
DWB — EXPLANATION OF THE DISABILITY REQUIREMENT AND THE PRESCRIBED PERIOD
To be considered disabled, a widow, widower, or surviving divorced spouse (age 50
to 60) must have a physical or mental condition that is severe enough to keep a person
from working. The condition must have lasted or be expected to last for at least 12
months in a row.
The person's disability must start:
not later than 7 years after the month of death of the wife or husband, or;
for a widow, widower or surviving divorced spouse formerly entitled to mother's or
father's benefits not later than 7 years after the month those benefits ended, or;
for a widow/widower or surviving divorced spouse who was previously disabled and who
becomes disabled again, not later than 7 years after the period of disability ended.
|
320.9.
|
DESCRIPTION OF EARNINGS REQUIREMENT-SPECIAL INSURED STATUS REQUIREMENTS FOR SUBSEQUENT
PERIOD OF DIB
A person who had a period of disability which began before age 31, subsequently recovered,
and then became disabled again before or after age 31, can meet the earnings requirement
if he/she had one quarter of coverage for every two calendar quarters after age 21
and through the quarter in which the later period of disability began, excluding the
prior period of disability.
|
321.
|
ALLOWANCE-SUBSEQUENT PERIOD FO DIB, SPECIAL INSURED STATUS-BENEFITS PAYABLE 5/83,
FIRST POSSIBLE MONTH OF ENTITLEMENT EARLIER
It is determined your period of disability began 1. Your disability benefits are based on a special provision of the Social Security
Act. The first month for which benefits are payable to you under this provision is
May 1983.
Fill
in:
-
|
322.2.
|
DIB DENIAL — EARNINGS REQUIREMENT NOT MET — NO QC AT ANY TIME
Your Social Security record shows that you do not have credit for any work under Social
Security. A disabled person can get disability benefits only if the person worked
long enough under Social Security. Since you do not meet the earnings requirement
of the law, you cannot get disability benefits.
|
322.3.
|
DIB DENIAL — AOD BEFORE AGE 24 — 6/12 TEST NOT MET IN AOD OR LATER
Your Social Security record shows that you do not meet the earnings requirement of
the law. You have earned Social Security credits for only 1 calendar quarters of work in the 12-quarter (3 year) period ending 2. This is the last day of the calendar quarter in which you state you became unable
to work because of your condition. Your Social Security record also shows that you
do not meet the earnings requirement on any later date. Since you do not meet this
requirement, it has not been necessary to decide whether you are disabled within the
meaning of the law.
Fill
ins:
-
1.
Number of acquired quarters
-
|
322.4.
|
DIB DENIAL — AOD BETWEEN AGES 24-31 EARNINGS REQUIREMENT NOT MET IN AOD OR LATER
Your Social Security record shows that you do not meet the earnings requirement of
the law. You have earned Social Security credits for only 1 calendar quarters of work in the period beginning with the first calendar quarter
after you reached 21 and ending with 2. This is the last day of the calendar quarter in which you state you became unable
to work because of your condition. Your Social Security record also shows that you
do not meet the earnings requirement on any later date. Since you do not meet this
requirement, it has not been necessary to decide whether you are disabled within the
meaning of the law.
Fill
ins:
-
-
|
322.6.
|
DIB DENIAL — AOD AT EARLY AGE — EARNINGS REQUIREMENT NOT MET
Your earnings record shows you do not have enough work credits under Social Security
at any time to qualify for disability benefits. Therefore, it has not been necessary
to decide whether you are disabled within the meaning of the law.
|
322.7.
|
DIB DENIAL — EARNINGS REQUIREMENT NOT MET IN AOD (AOD 1973 OR LATER) DISABILITY DUE
TO STATUTORY BLINDNESS
Your Social Security record shows that you do not meet the earnings requirement of
the law. A person whose disability is due to statutory blindness meets the earnings
requirement if one Social Security credit has been earned for each calendar year elapsing
after 1950 (or after age 21, if that is later) up to the year the disability began.
To meet this requirement, you need 1 Social Security credits. You have only 2 credits towards this requirement. Your Social Security record also shows that you
do not meet the earnings requirement at any later date. Since you do not meet this
requirement, it has not been necessary to decide whether you are disabled within the
meaning of the law.
Fill
ins:
-
-
2.
Number of credited quarters
|
323.1.
|
DWB DENIAL — DISABLED WHEN ALLEGED OR ONSET ESTABLISHED LATER THAN ALLEGED — PRESCRIBED
PERIOD REQUIREMENT NOT MET
To receive disability benefits, your condition must have been disabling within the
meaning of the law on or before 1, the date the specified 7-year period ended for you.
After carefully studying the medical evidence in your claim and your statements, it
has been determined that your condition first became severe on 2. Since your condition was not disabling within the 7-year period, you are not entitled
to disability benefits.
Fill
ins:
-
-
|
323.2.
|
DIB DENIAL — DISABLED IN QUARTER ALLEGED OR ONSET ESTABLISHED LATER THAN ALLEGED —
DISABLED BEFORE AGE 24 — 6/12 TEST NOT MET
After carefully studying your record and the medical evidence, it has been determined
that your condition first prevented you from doing substantial gainful work on 1. However, you do not meet the earnings requirement at that time or at any later time.
Your Social Security record shows that you have earned credits for only 2 calendar quarters in the 12-quarter (3-year) period ending 3.
Fill
ins:
-
-
-
|
323.3.
|
DIB DENIAL — DISABLED IN QUARTER ALLEGED OR ONSET ESTABLISHED LATER THAN ALLEGED —
DISABLED BETWEEN THE AGES 24-31 — EARNINGS REQUIREMENT NOT MET
After carefully studying your records and the medical evidence, it has been determined
that your condition first prevented you from doing substantial gainful work on 1. However, you do not meet the earnings requirement at that time or any later time.
Your Social Security records shows that you have earned credits for only 2 calendar quarters beginning with the first calendar quarter after you reached 21
and ending with the quarter in which you became unable to work because of your condition.
Fill
ins:
-
-
|
323.4.
|
DIB DENIAL — DISABLED IN QUARTER ALLEGED OR ONSET ESTABLISHED LATER THAN ALLEGED —
DISABLED AGE 31 OR LATER — EARNINGS REQUIREMENT NOT MET — DISABILITY NOT DUE TO STATUTORY
BLINDNESS
After carefully studying your records and the medical evidence, it has been determined
that your condition first prevented you from doing substantial gainful work on 1. But, you do not meet the earnings requirement on that date or on any later date.
For a person whose disability began at age 31 or later there are two provisions of
the earnings requirement which must be met.
To meet the first provision of the earnings requirement a person needs 20 Social Security
credits in the 40-quarter period ending with the quarter in which you became disabled.
(a) You have credit for only 2 calendar quarters of work in this period. (b) You have the required quarters.
To meet the second provision of the earnings requirement a person needs one Social
Security credit for each year after 1950 (or after reaching age 21, if this is later)
up to the year in which you become disabled. You need 3 credits to meet this requirement. (c) You have credit for only 4 quarters of work or (d) You have the required credits.
Fill
ins:
-
-
-
-
|
323.5.
|
DIB DENIAL — DISABLED IN QUARTER ALLEGED OR ONSET ESTABLISHED LATER THAN ALLEGED —
DISABILITY DUE TO STATUTORY BLINDNESS — EARNINGS REQUIREMENT NOT MET — EOD 1/73 OR
LATER
After carefully studying your records and the medical evidence, it has been determined
that your condition first prevented you from doing substantial gainful work on 1. But, you do not meet the earnings requirement on that date or on any later date.
You need one Social Security credit for each year elapsing after 1950 (or after age
21, if that is later) up to the year you became disabled.
A minimum of 6 credits is needed. The credits may have been earned at any time. In
your case, this is a total of 2 credits. Your social security record shows that you have only 3 credits in this period.
Fill
ins:
-
-
-
|
324.
|
CLAIM FILED AFTER DEATH — NOT DISABLED AT ANY TIME EARNINGS REQUIREMENT MET — MEDICAL
CONSIDERATION ALONE
1 condition was not disabling on any date through 2, when 3 was last insured for disability benefits. In deciding this, we considered the medical
evidence, your statements, and how the condition affected 4 ability to work.
Fill
ins:
-
-
2.
Date disability I/S last met
-
-
|
324(A).
|
DIB — NOT DISABLED BEFORE INSURED STATUS EXPIRED
We have determined that your condition was not disabling on any date through 1, when you were last insured for disability benefits. In deciding this, we studied
your records, including the medical evidence and your statements, and considered your
age, education, training and work experience in determining how your condition affected
your ability to work.
Fill
in:
-
1.
Date disability I/S expired
|
324(B).
|
CLAIM FILED AFTER DEATH — NOT DISABLED AT ANY TIME EARNINGS REQUIREMENT MET
1 condition was not disabling on any date through 2, when 3 was last insured for disability benefits. In deciding this, we considered how much
4 condition had affected 4 ability to work. We studied 4 records, including the medical evidence and your statements, and considered 4 age, education, training, and work experience.
Fill
ins:
-
-
2.
Date disability I/S last met
-
-
|
324.2
|
WIDOW(ER) NOT DISABLED BEFORE PRESCRIBED PERIOD EXPIRED
We have determined that your condition was not disabling on any date before 1, the date your prescribed period ended. In deciding this, we considered the medical
evidence and your statements.
Fill
in:
-
1.
MM/DD/YY (last day of the P/P)
|
329.
|
CLAIM FILED AFTER DEATH — NOT DISABLED — LACK OF SEVERITY — MEDICAL CONSIDERATION
ALONE
1 condition was not severe enough to prevent 2 from doing any substantial gainful work, nor was it the cause of death. In deciding
this, we considered the medical evidence, your statements, and how the condition affected
3 ability to work.
Fill
in:
-
-
-
|
330.
|
LACK OF SEVERITY (THIS PARAGRAPH IS NOT USED IN CDB DENIALS.)
We have determined that your condition is not severe enough to keep you from working.
We considered the medical and other information and work experience in determining
how your condition affects your ability to work.
|
330(A).
|
ADVICE REGARDING WORSENING OF CONDITION
If 1 condition gets worse and keeps 2 from working, please contact any Social Security office about filing another application.
Fill ins:
-
-
2.
You/him/her/claimant's name
|
330(B).
|
DWB DENIAL — ADVICE REGARDING WORSENING OF CONDITION
If 1 condition gets worse, please contact any Social Security office about filing another
application. The last day of 2 specified 7-year period is 3.
Fill
ins:
-
-
2.
Your/his/her/claimant's name
-
3.
MM/DD/YY (last day of the P/P)
|
330(D).
|
ADVICE REGARDING FAILURE TO FOLLOW PRESCRIBED TREATMENT DECISION
If 1 decide to follow prescribed treatment, or if you have more information showing why
2 should not, please contact any Social Security office.
Fill ins:
-
-
|
330(E).
|
ADVICE REGARDING DRUG ADDICTION OR ALCOHOLISM MATERIAL DECISION
If 1 a new or worsening condition other than drug addiction and/or alcoholism, please
contact any Social Security office about filing another application.
Fill in:
-
1.
You have/claimant's name has
|
330.1.
|
WIDOW(ER)'S IMPAIRMENT NOT SUFFICIENTLY SEVERE
We have determined that your condition is not severe enough to be considered disabling.
In deciding this, we considered the medical evidence and your statements.
|
330.2.
|
CLAIM FILED AFTER DEATH — NOT DISABLED — LACK OF SEVERITY
1 condition was not severe enough to keep 2 from doing any substantial gainful work, nor was it the cause of 3 death. In deciding this, we considered how much 1 condition had affected 3 ability to work. We studied 1 records, including the medical evidence and your statements, and considered 3 age, education, training and work experience.
Fill
ins:
-
-
-
|
330.3.
|
IMPAIRMENT NOT SEVERE — MEDICAL CONSIDERATION ALONE
We have determined that your condition is not severe enough to be considered disabling.
In deciding this, we considered the medical records, your statements, and how your
condition affects your ability to work.
|
330.4.
|
DIB — IMPAIRMENT NOT SEVERE — MEDICAL CONSIDERATION ALONE — NOT DISABLED BEFORE INSURED
STATUS EXPIRED
We have determined your condition was not disabling on any date through 1, when you were last insured for disability benefits. In deciding this, we considered
the medical records, your statements, and how your condition affected you ability
to work.
Fill
in:
-
1.
Date disability I/S expired
|
330.5.
|
CDB — IMPAIRMENT NOT SEVERE — MEDICAL CONSIDERATION ALONE OR CONDITION DISABLING BUT
DID NOT EXIST BEFORE AGE 22 (AGE 22 OR OLDER)
We have determined that your condition was not disabling before age 22. In deciding
this, we considered the medical records, your statements and how your condition affected
your ability to work.
|
330.6.
|
DIB DENIAL — EXPLANATION OF DISABILITY REQUIREMENT
To be considered disabled, a person must be unable to do any substantial gainful work
due to a medical condition which has lasted or is expected to last for at least 12
months in a row. The condition must be severe enough to keep the person from working
not only in his or her usual job but in any other substantial gainful work. We look
at the person's age, education, training and work experience when we decide whether
he or she can work.
|
330.8.
|
CDB — IMPAIRMENT NOT SEVERE — MEDICAL CONSIDERATION ALONE (NOT YET AGE 22)
We have determined that your condition is not disabling. In deciding this, we considered
the medical evidence and your statements.
|
331.
|
IMPAIRMENT PREVENTS SGA AT TIME OF ADJUDICATION BUT IS NOT EXPECTED TO PREVENT SGA
FOR A PERIOD OF 12 MONTHS
We have determined that your condition is not expected to remain severe enough for
12 months in a row to keep you from working. In deciding this, we considered the medical
evidence, your statements and how your condition affected your ability to work.
|
331(A).
|
ADVICE REGARDING FAILURE TO IMPROVE — IMPAIRMENT IS SEVERE BUT IS NOT EXPECTED TO
LAST 12 MONTHS
If 1 condition does not improve as expected, please contact any Social Security office.
Fill in:
-
|
331(C).
|
APPLICATION FILED AFTER PRIOR DENIAL, CONSIDERATION OF NEW AND FORMER EVIDENCE
In considering your current application of 1, we reviewed not only the new evidence submitted but also all the earlier evidence
sent in with your previous application.
Fill
in:
-
|
331(D).
|
APPLICATION FILED MORE THAN 12 MONTHS AFTER PERIOD OF DISABILITY ENDS
Under the law, a period of disability cannot be established which ends more than 12
months before the month the application is filed.
|
331(E).
|
CLAIM FILED AFTER DEATH — NOT DISABLED — IMPAIRMENT IS SEVERE AT TIME OF DEATH BUT
WOULD NOT HAVE BEEN EXPECTED TO LAST 12 MONTHS
1 condition was severe at the time of 2 death; however it was not expected to last for 12 months in a row, nor was it the
cause of 2 death. In deciding this, we studied 2 records, including the medical evidence and statements in file, and considered 2 age, education, training and work experience.
Fill
ins:
-
-
|
331.1.
|
IMPAIRMENT PREVENTED SGA FOR A PERIOD OF LESS THAN 12 MONTHS
We have determined that your condition was not severe enough for 12 months in a row
to keep you from working. In deciding this, we considered the medical evidence, your
statements and how your condition affected you ability to work.
|
331.1(A)
|
CLAIM FILED AFTER DEATH – NOT DISABLED —IMPAIRMENT NO LONGER SEVERE AT TIME OF DEATH
AND DID NOT PREVENT SGA FOR A PERIOD OF AT LEAST 12 MONTHS
1 condition was not severe enough for 12 months in a row to keep 2 from working, nor was it the cause of 3 death. In deciding this, we considered how much 1 condition had affected 3 ability to work. We studied 1 records, including the medical evidence and statements in file, and considered 3 age, education, training and work experience.
Fill
ins:
-
-
-
|
331.2.
|
WIDOW(ER)’S IMPAIRMENT NOT EXPECTED TO PREVENT SGA FOR A PERIOD OF 12 MONTHS
We have determined that your condition is not expected to remain severe enough for
12 months in a row to keep you from working. In deciding this, we considered the medical
evidence and your statements.
|
331.3.
|
WIDOW(ER)’S IMPAIRMENT PREVENTED SGA FOR A PERIOD OF LESS THAN 12 MONTHS
We have determined that your condition was not severe enough for 12 months in a row
to keep you from working. In deciding this, we considered the medical evidence and
your statements.
|
332(A).
|
CDB DENIAL — CLAIMANT ABLE TO ENGAGE IN SGA
We have determined that you are not entitled to childhood disability benefits. After
carefully studying your record, it has been determined from the evidence that the
work you are doing despite your handicap shows you are able to do some type of substantial
gainful work. Therefore, you do not meet the disability requirement of the law.
It is important for you to know that we have not made any determination as to whether
or not your medical condition is severe enough to meet the disability requirement.
Since you are engaging in substantial gainful work, it has not been necessary to evaluate
the severity of your medical condition.
|
341.
|
EVIDENCE INSUFFICIENT FOR DISABILITY DECISION — CLAIMANT UNCOOPERATIVE IN SUBMITTING
ADDITIONAL EVIDENCE
Under the law, the applicant is responsible for furnishing evidence to support the
claim. Although you have been requested to furnish additional evidence, you have not
done so. Therefore, a determination has been made based on the evidence in file. This
evidence does not show that you are disabled.
|
341(A)
|
CLAIM FILED AFTER DEATH — INSUFFICIENT EVIDENCE
Under the law, the applicant is responsible for furnishing evidence to support his/her
disability claim. Although you have been requested to furnish additional evidence,
you have not done so. Therefore, a determination has been made based on the evidence
in file. This evidence does not show that 1 condition was disabling.
Fill
in:
-
|
341(B)
|
CDB DENIAL - EVIDENCE INSUFFICIENT FOR DISABILITY DECISION — CLAIMANT COOPERATIVE
In order to be entitled for childhood disability benefits, your impairment must be
found to be severe prior to age 22. The evidence in file is not sufficient to fully
evaluate your claim and the evidence needed cannot be obtained. Therefore, a determination
has been made based on the evidence in file. The evidence does not show that you are
disabled on or before your 22nd birthday.
|
342.
|
EVIDENCE INSUFFICIENT FOR DISABILITY DECISION — CLAIMANT REFUSES OR DOES NOT REPORT
FOR CONSULTATIVE EXAMINATION
The evidence we now have does not show that your condition is disabling. We based
our determination on this evidence because you did not take the medical examination
we asked you to have at our expense. The examination was needed to fully evaluate
your condition.
|
343.
|
CLAIMANT DOES NOT WISH TO PURSUE — WANTS DECISION ON EVIDENCE IN FILE
Since you did not wish to continue the processing of your claim, we determined, based
on the evidence in your file, that your condition is not disabling.
|
343(A).
|
DIB, CDB, DWB — CLAIMANT DOES NOT PURSUE AND DOES NOT INDICATE DECISION TO BE MADE
ON EVIDENCE IN FILE
Since you did not wish to continue the processing of your claim, we determined, based
on the evidence in your file, that your condition is not disabling. You may withdraw
your claim and this determination will no longer be in effect. Your Social Security
office will assist you if you wish to withdraw.
|
343(C).
|
CLAIM FILED AFTER DEATH — DENIAL — APPLICANT DOES NOT WANT TO CONTINUE DEVELOPMENT
OF CLAIM
Since you did not wish to continue the processing of 1 claim, we determined, based on the evidence in file, that 2 was not disabled.
Fill
ins:
-
-
|
350.
|
FREEZE DOES NOT INCREASE RIB CURRENTLY PAYABLE
R
Since the amount of your benefit would not be increased by refiguring it under the
disability provision, we are denying your application for a disability determination.
Your benefit amount will continue unchanged.
|
351.
|
APPLICANT MENTIONS ANOTHER DISABILITY PROGRAM
Definitions of disability are not the same in all government and private disability
programs. Government agencies must follow the particular laws which apply to their
disability programs. Therefore, a finding by a private organization or another government
agency that a person is disabled would not necessarily mean that the person is disabled
as defined in the Social Security Act.
|
354.
|
REEXAMINATION SCHEDULED — BENEFICIARY HOSPITALIZED
The evidence in your claim shows that your condition may soon improve. Therefore,
we plan to get in touch with you about 1 to see if your are still eligible to receive disability benefits. To help us determine
this, we may ask you to submit additional medical evidence or go for a medical examination.
If we find you are still disabled, your benefits will continue. But, if our review
shows you are no longer disabled, your benefits will be stopped.
RESPONSIBILITIES OF PEOPLE RECEIVING DISABILITY BENEFITS
Please notify us promptly if you should leave the hospital. You should also report,
without delay, any of the other events listed in the enclosed booklet.
If you have questions about your claim, the people in any Social Security office will
be glad to help you. You can find the telephone number and address in the telephone
book under “Social Security Administration,” or ask for this information at your local
post office.
Enclosure: SSA-10153
Fill
in:
-
|
358.
|
STATUTORY BLINDNESS — DIB ALLOWANCE UNDER 1972 AMENDMENTS — FIRST MONTH OF ENTITLEMENT
RESTRICTED TO 1/73
Under the law, in effect before 1972, disability benefits were payable only if a disabled
individual was fully insured and had 20 Social Security credits in the 40-quarter
(10-year) period ending in or after a quarter in which he was disabled. Although you
meet the disability requirement and are fully insured, your Social Security record
shows that you have only 1 credits in the 40-quarter period ending 2, the last day of the calendar quarter in which you became disabled. Thus, you do
not meet the earnings requirement in effect before the 1972 amendments.
The 1972 amendments changed the earnings requirement a statutorily blind person must
meet to be entitled to disability benefits. It has been determined that you meet the
new requirement. You are entitled to disability insurance benefits beginning with
the month shown above. This is the earliest date benefits can be paid under the 1972
amendments to the Social Security Act.
Fill
ins:
-
-
|
360.
|
NOTICE TO NH WHEN DISABILITY DENIED IN DIB/RIB CLAIM
To be considered disabled for Social Security purposes, you must be unable to perform
any substantial gainful work because of a physical or mental impairment which has
lasted or is expected to last at least 12 continuous months or is expected to result
in death.
|
365.
|
INITIAL NOTICE — REFERENCE TO FOLLOW-UP NOTICE IF TITLE II UNDERPAYMENT OR OVERPAYMENT
INVOLVED
You will be notified at a later date if an underpayment or overpayment of benefits
exists on your claim.
|
366.
|
LEAD-IN PARAGRAPH — UNDERPAYMENT OF TITLE II BENEFITS INVOLVED
You were previously notified in our notice dated 1 that the last payment to which you are entitled is for the month of 2. This follow-up notice is to inform you about the underpayment on your claim.
Fill
ins:
-
1.
Date initial cessation notice
-
|
367.
|
LEAD-IN PARAGRAPH — OVERPAYMENT OF TITLE II BENEFITS INVOLVED
You were previously notified in our notice dated 1 that the last payment to which you are entitled is for the month of 2. This follow-up notice is to inform you about the overpayment on your claim.
Fill
ins:
-
1.
Date initial cessation notice
-
|
368.
|
LEAD-IN PARAGRAPH — MEDICAL PREMIUMS DUE
You were previously notified in our notice dated 1 that the last payment to which you are entitled is for the month of 2. This follow-up notice is to inform you about the medical premiums due on your claim.
Fill
ins:
-
1.
Date initial cessation notice
-
|
372.
|
DIB-RATE INCREASE — TWO RATES PAYABLE
As a result of a change in the law, you are entitled to disability benefits in two
different amounts beginning at two different times. Under the previous law, you were
entitled to the smaller amount. Under the current law, your benefits have been refigured
and you are entitled to a larger amount.
|
374.
|
DIB — RATE INCREASE — CHANGE IN DISABILITY PERIOD
Your monthly disability insurance benefit has been increased to the amount shown above.
The first payment will include the difference due for back benefits from the date
of entitlement shown above. This increase is paid because of a recent change in the
disability provisions of the Social Security Act permitting the use of a longer period
of disability for you than was possible when you filed your application.
NOTE: For RIB delete the word "disability" in the first line.
|
378.
|
CLAIMANT INSURED FOR RIB — NO RIB CLAIM FILED
Your present earnings record and the date of birth you gave us show that you have
enough credit for work under Social Security to qualify for retirement insurance benefits
at age 62.
|
379.
|
INFORMATION CONCERNING HOSPITAL AND MEDICAL INSURANCE — CLAIMANT AGE 63-64 3/4
You may be eligible for hospital and medical insurance benefits when you reach 65.
If you wish to enroll for this health insurance, please get in touch with any Social
Security office about 3 months before you become 65.
|
380.
|
DIB AND DWB APPLICATIONS FILED
R
If you have not already been informed about the determination on your other disability
application, you can expect to be notified shortly.
|
381.
|
FAILS TO FOLLOW PRESCRIBED TREATMENT
We have determined that you are not entitled to 1 because you are not following the treatment prescribed for you. A person who is unable
to do substantial gainful work may qualify for 2, but not if he/she refuses to follow prescribed treatment that could restore his/her
ability to work.
Fill
ins:
-
1.
Disability benefits/supplemental security income payments
-
|
381(A).
|
CLAIM FILED AFTER DEATH — DENIAL — IMPAIRMENT WAS SEVERE BUT NUMBER HOLDER FAILED
TO FOLLOW PRESCRIBED TREATMENT
1 was not entitled to disability benefit because 2 was not following the treatment prescribed for 3 at the time of 4 death. A person who is unable to do substantial gainful work may qualify for disability
benefits, but not if he/she refuses to follow prescribed treatment that could restore
his/her ability to work.
Fill
ins:
-
-
-
-
|
381(B).
|
CHILDHOOD DISABILITY CLAIM — DENIAL — IMPAIRMENT IS SEVERE BUT CLAIMANT FAILS TO FOLLOW
PRESCRIBED TREATMENT
We have determined that you are not entitled to childhood disability benefits. The
evidence shows that you are unable to perform substantial gainful work due to your
condition, but that you are not following the treatment which has been prescribed
for you. Therefore, childhood disability benefits may not be paid to you.
Childhood disability insurance benefits may be paid to a person age 18 or older if
the person is unable to perform any substantial gainful work due to a medically determinable
impairment which began before age 22.
Despite prescribed treatment, the condition must have lasted or be expected to last,
for a continuous period of at least 12 months. However, if a person refuses to follow
prescribed treatment that could restore the individual's ability to work, the person
may not become entitled to childhood disability benefits.
If you should decide to follow the prescribed treatment, or if you have more information
showing why you should not, please get in touch with any Social Security office.
|
386.
|
FREEZE CESSATION — MEDICAL IMPROVEMENT (W/E RECEIVING REDUCED RIB)
The law provides that an individual's disability freeze shall end if his condition
improves so that the person becomes able to do substantial gainful work. The law also
provides that an individual's freeze period will continue for the month the disability
ends and the following two months. The medical evidence in your case shows that your
condition has improved to the extent that you became able to do substantial gainful
work in 1. Accordingly, the last month of your disability freeze is 2. This decision is based on all the evidence in your file, including any additional
evidence you may have submitted.
Fill
ins:
-
-
|
386(A).
|
FREEZE CESSATION — WORK ACTIVITY (W/E RECEIVING REDUCED RIB)
The law provides that an individual's disability freeze shall end if the person becomes
able to do substantial gainful work. The law also provides that an individual's freeze
period will continue for the month the disability ends and the following 2 months.
The evidence in your case shows that you became able to do substantial gainful work
in 1. Accordingly, the last month of your disability freeze is 2. This decision is based on all the evidence in your file, including any additional
evidence you may have submitted.
Fill
ins:
-
-
|
388.
|
FREEZE OR DIB CONTINUANCE (AFTER FULL RETIREMENT AGE)
The law provides that a disability period shall end when an individual reaches full
retirement age or again becomes able to do substantial gainful work, whichever occurs
first. On the basis of the evidence in your case, we find that your disability continued
until you reached full retirement age.
|
396.
|
DWB CESSATION — MEDICAL IMPROVEMENT
You have been receiving benefits under a special provision of the Social Security
Act which provides for the payment of benefits to disabled widows and widowers under
age 60. To qualify for such benefits an individual must have a condition so severe
as to ordinarily prevent her/him from working. Medical conditions which meet this
requirement are described in the Social Security Regulations; disability benefits
end when this requirement is not met. The law continues benefits, however, for 2 months
after the month in which the person's condition does not meet the disability requirement
of the law. The medical evidence in your case shows that your condition does not meet
the disability requirement of the law in 1. Accordingly, the last disabled 2 benefit check to which you are entitled is for the month of 3.
If your condition worsens you should contact your Social Security office about filing
a new application.
Fill
ins:
-
-
-
|
397.
|
DIB CESSATION — OVERPAYMENT INVOLVED
Our records show you received $1 more in Social Security benefits than you should have. This is because you were paid
benefits for 2 months after 3.
Fill
ins:
-
-
2.
Number of months overpaid
-
3.
Last MM/YY benefits are due
(2)
|
397(A).
|
DIB CESSATION — OVERPAYMENT INVOLVED — SMI PREMIUMS INCLUDED IN OVERPAYMENT
Our records show you received $1 more in Social Security benefits than you should have. This happened because you
were paid benefits for 2 months after 3. The above amount includes medical insurance premiums of $4 which were withheld from your benefit check(s) for the same period.
Fill
ins:
-
-
2.
Number of months overpaid
-
3.
Last MM/YY benefits are due
-
4.
Amount of medical insurance premiums included in the overpayment
|
398.
|
DIB CESSATION — UNDERPAYMENT INVOLVED FOR ONE MONTH
Since you were last paid for the month of 1, you are due benefits for 2. You may expect to receive a check in the amount of $3 from the Treasury Department within a few days. This check will represent all payment
due you.
Fill
ins:
-
1.
MM/YY (last month benefit paid)
-
2.
MM/YY (month payment is due)
-
|
398(A).
|
DIB CESSATION — UNDERPAYMENT INVOLVED FOR MULTIPLE MONTHS
Since you were last paid for the month of 1, you are due benefits for 2 through 3. You may expect to receive a check in the amount of $ 4 from the Treasury Department within a few days. This check will represent all payments
due you.
Fill
ins:
-
1.
Month/year (last month benefit paid)
-
2.
Month/year (first month benefit payment is due)
-
3.
Month/year (last month benefit payment is due)
-
|
399.
|
TITLE II “LEAD-IN” PARAGRAPH
This notice concerns your continuing entitlement to benefits under the Social Security
Disability program.
|
399(A).
|
REQUEST FOR REFUND
You should refund the amount shown above within 30 days from the receipt of this letter.
Please make your check or money order payable to “Social Security Administration,
Claim No. 1,” and send it to us in the enclosed envelope.
Enclosure: Envelope
Fill
in:
-
1.
Claim number (include BIC)
|
400.
|
DWB CESSATION (NO TRIAL WORK PERIOD)
A widow, widower or surviving divorced spouse may be considered disabled for Social
Security purposes only if she or he has a medical condition that is so severe as to
ordinarily prevent an individual from working. Widow's or widower's benefits based
on disability end if she or he engages in substantial gainful activity since she or
he is no longer considered to be disabled within the meaning of the law. The law continues
her or his benefits, however, for the month in which disability ends and the following
two months. The evidence in your case shows that you became able to do substantial
gainful activity in 1. Accordingly, the last widow's or widower's benefit to which you are entitled is
for the month of 2 . If your condition again prevents you from working, you should contact your Social
Security office about filing a new application.
Fill
ins:
-
-
|
401.
|
DWB CESSATION (TRIAL WORK PERIOD)
A widow, widower or surviving divorced spouse may be considered disabled for Social
Security purposes only if she or he has a medical condition that is so severe as to
ordinarily prevent an individual from working. Widow's or widower's benefits based
on disability end if she or he engages in substantial gainful activity since she or
he is no longer considered to be disabled within the meaning of the law. The law continues
her or his benefits, however, for the month in which disability ends and the following
two months. Not until a person has performed services in at least 9 months is a decision
made as to whether the person has become able to do substantial gainful work. The
evidence in your case shows that you have performed services in at least 9 months
and that you became able to do substantial gainful work in 1. Accordingly, that last widow's or widower's benefit to which you are entitled is
for the month of 2. If your condition again prevents you from working, you should contact your Social
Security office about filing a new application.
Fill
ins:
-
-
|
402.
|
AOD BEFORE AGE 62 YEARS 7 MONTHS BUT ONSET CANNOT BE ESTABLISHED BEFORE AGE 62 YEARS
7 MONTHS OR LATER — LESS THAN 29 MONTHS OF PAST AND/OR FUTURE DISABILITY ENTITLEMENT
PRIOR TO AGE 65
We have determined that you are not entitled to Medicare coverage for the disabled.
However, you may be entitled to Medicare coverage at age 65, whether or not you are
disabled. A person must be disabled for 1 months before his/her Medicare coverage begins. Because your condition was not disabling
on any date through 2, your Medicare coverage could not begin until you reach age 65.
Fill
ins:
-
1.
29 (for NH and disabled widow(er) claims/24 (for disabled child claims)
-
2.
Date claimant is age 62 and 7 months (for NH or disabled widow(er) claims/date claimant
is age 63 (for CDB claims).
|
407(A).
|
UNDERPAYMENT AWARD IN ADDITION TO OTHER AWARD (BENEFIT OF WIFE INCLUDED WITH PAYMENT)
This payment includes unpaid benefits which were due your husband. It also includes
wife's benefits due you.
|
408.
|
DISABILITY CEASES — PAYMENTS CONTINUE
Medical evidence shows that you became able to do substantial gainful work in 1. Even though you are able to work, you will get disability benefits. Your benefits
will continue because you are in an approved vocational rehabilitation program that
you started when your condition was not expected to improve.
We will contact you in 2 to see if you are still in the program. If your program stops or changes before that
date, let us know.
Fill
ins:
-
-
|
409.
|
PERSONALIZED NOTICE LEAD-IN
Attached is an explanation of how we decided your claim.
|
410.
|
TITLE II — VR CESSATION — AUXILIARIES IN SEPARATE HOUSEHOLDS — PAYMENTS CONTINUE
We have determined that 1 is no longer disabled under the Social Security law. However, benefits will be continued
because of the wage earner's participation in a State vocational rehabilitation program.
If you are not satisfied with our finding that the worker's period of disability ended,
you may request that your case be reexamined not later than 60 days from the date
you receive this notice even though your payments are being continued based on vocational
rehabilitation involvement.
Fill-in:
-
1.
Name of primary beneficiary
|
411.
|
TITLE II — VR CESSATION — AUXILIARIES IN SAME HOUSEHOLD — PAYMENTS CONTINUE
Due to your participation in a State vocational rehabilitation plan, benefits to 1 will continue.
Fill
in:
-
1.
Your family/your wife/your children/your child
|
412.
|
DISABILITY CEASES — PAYMENTS TERMINATE
Your benefits will stop because evidence shows that you recovered enough to do substantial
gainful work in 1.
Fill
in:
-
If you were in an approved State vocational rehabilitation program you might be able
to keep getting benefits.
Appropriate paragraph from the following:
1) However, rehabilitation records show that your program ended in 1.
Fill in:
-
2) However, the rehabilitation agency records show that you stopped taking part in
an approved program in 1.
Fill
in:
-
1.
MM/YY active participation in VR program ended
3) We have determined that you are not eligible for continued payments because your
vocational rehabilitation program will not give you new special skills or a job at
the end of the program.
4) We have determined that you are not entitled to continued payments because your
disability claim was set for review in 1. This means you were expected to recover before your rehabilitation program ends
in 2.
Fill
ins:
-
-
2.
MM/YY rehabilitation program will end
5) Your disability ended 1 and your vocational rehabilitation program ended 2. Continued payment is not possible because your vocational program ended before your
last month of entitlement of disability benefits.
Fill
ins:
-
-
6) Although you are in a vocational rehabilitation program, your program was approved
after your disability ended.
1 is the last month you are entitled to 2. 3 payments are paid for the month disability ends and for the 2 following months.
Fill
ins:
-
1.
MM/YY disability terminated
-
2.
A disability benefit/a supplemental security income payment
-
3.
Disability/Supplemental Security income
NOTE: When this paragraph is requested in word processing, it should be requested as 412.1,
412.2, 412.3, 412.4, 412.5 or 412.6 (see NL 00702.200).
|
413.
|
TITLE II — VR CONTINUED PAYMENTS — TERMINATION PARAGRAPH
Our 1 notice to you explained that you would get disability benefits as long as you were
in an approved vocational rehabilitation program. Because your program ended 2, your disability benefits must also end then.
If you do not agree with this decision, you can ask to have your claim reviewed.
Fill
ins:
-
-
2.
MM/YY VR program termination
|
414.
|
TITLE XVI — VR CONTINUED PAYMENTS — TERMINATION PARAGRAPH
Our 1 notice to you explained that you would get disability benefits as long as you were
in an approved vocational rehabilitation program. Because your program ended 2 your disability benefits must also end then.
If you do not agree with this decision, you can ask for a hearing by the Office of
Hearings and Appeals.
Fill
ins:
-
-
2.
MM/YY VR program termination
|
415.
|
TITLE II — VR CESSATION — AUXILIARIES IN SEPARATE HOUSEHOLDS — VR PAYMENTS TERMINATE
This notice concerns your continuing eligibility to benefits.
We cannot continue to pay you benefits. The person on whose Social Security record
you filed a claim is no longer entitled to continued payments because he or she is
no longer participating in a State vocational rehabilitation program.
Therefore, 1 is the last month you will receive benefits.
Fill
in:
-
1.
MM/YY disability terminated
|
416.
|
TITLE XVI CLAIM ESCALATED TO RECONSIDERATION LEVEL
Because you had already requested reconsideration on your Social Security disability
claim when you filed your Supplemental Security Income claim, we processed your Supplemental
Security Income claim as though you had requested reconsideration on it as well. Thus,
this determination is both an initial and reconsideration determination.
|
417.
|
TITLE II — VR CESSATION — AUXILIARIES IN THE SAME HOUSEHOLD — VR PAYMENTS TERMINATE
This notice concerns 1 continuing eligibility to benefits. We cannot continue to pay 2 benefits because you are no longer participating in a State vocational rehabilitation
program, and therefore are no longer entitled to continued payments. Therefore, 3 is the last month benefits are payable.
Fill
ins:
-
1.
Your family's/your wife's/your children's/your child's
-
-
3.
MM/YY disability terminated
|
430.
|
INCREASE IN RATE — BENEFITS PAYABLE AT BOTH RATES
The increase in the rate of benefits beginning 1 is possible due to the termination of benefits to 2 effective that month.
Fill
ins:
-
-
2.
Name of terminated beneficiary
|
432.
|
DECREASE IN RATE — BENEFITS PAYABLE AT BOTH RATES
The higher rate of benefit allowed before 1 is possible because 2 did not become entitled to benefits until that month. Thereafter, it was necessary
under the provisions of the Social Security Act, that the rate be reduced as shown
above.
Fill
ins:
-
-
|
439.
|
CHANGE IN BENEFIT RATE
The benefits payable on this claim have been refigured. The new monthly rate and its
effective date are shown above.
|
439(A).
|
CHANGE IN BENEFIT RATE — INCREASE OR DECREASE IN BENEFITS FOR RETROACTIVE PERIOD
The benefits payable on this claim have been refigured. The new monthly rate and its
effective date are shown above. Your first payment will have been adjusted for the
difference between benefits already paid and those now payable.
|
440.
|
BENEFICIARY'S BENEFIT RATE ADJUSTED DUE TO TERMINATION OF BENEFITS TO ANOTHER BENEFICIARY
The benefit rate has been increased due to 1 of 2 on 3.
Fill
ins:
-
1.
Reason (item 11 of the SSA-101)
-
-
3.
Date (item 11 of the SSA-101)
|
441.
|
CHANGE IN ONE BENEFICIARY'S RATE — WAGE EARNER'S AND SPOUSE'S BENEFITS COMBINED
R
The benefit payable to you has been combined with the benefit payable to your spouse.
|
462.
|
FORM SSA-L562-U3 CHANGE IN RATE REASONS
Indicate only one reason for the fill-in space on the form:
-
A.
To correct the previous calculation
-
B.
To give credit for additional earnings
-
C.
To increase the rate because the benefits of another person have been terminated
-
D.
To decrease the rate because another person is now entitled to benefits
-
E.
To increase the rate because a period of disability has been established
-
F.
To give credit for months of entitlement before full retirement age (62) for which
less than the full benefit was paid
-
G.
To give credit for months of entitlement before full retirement age for which benefits
were paid based on caring for a child who was entitled to benefits
-
H.
To give credit for months your deceased spouse was entitled to, but not paid, full
benefits between age 62 and 65
-
I.
To give credit for months when you were at least full retirement age and did not receive
a retirement benefit because you were working
-
J.
Because of a special provision of the law. This special provision increases benefits
for people who have worked under Social Security for many years at relatively low
earnings
-
K.
To give credit for additional earnings and also to give credit for months after 1970
when you were at least full retirement age and did not receive a retirement benefit
because you were working
-
L.
To increase the benefits based on your amended annual report of earnings which shows
you worked in fewer months after full retirement age than you had originally reported
-
M.
To give credit for months your deceased spouse was at least 65 and did not receive
a retirement benefit because of work
NOTE: When this paragraph is requested in word processing, it should be requested as 462a,
462b, 462c, 462d, 462e, 462f, 462g, 462h, 462i, 462j, 462k, 462l, 462m (see NL 00702.200).
|
501.
|
DWB AND DIB AFFIRMATION OF DENIAL, CESSATION OR ONSET DATE — NON STATE — NO PHYSICIAN
PARTICIPATION
Upon receipt of your request for reconsideration, we had your claims for disabled
1 benefits and disability insurance benefits independently reviewed by a special group.
All the evidence in your case has been carefully evaluated; this includes the medical
evidence and the additional information received since the original decision. On the
basis of the evidence and your statements, we find that the previous determinations
were proper under the law.
Fill
in:
-
1.
Widow/widower/surviving divorced wife's/surviving divorced husband's
|
501(A).
|
DWB AND DIB — AFFIRMATION OF DENIAL, CESSATION OR ONSET DATE NON STATE — PHYSICIAN
PARTICIPATION
Upon receipt of your request for reconsideration, we had your claim for disabled 1 benefits and disability insurance benefits independently reviewed by a specially
designated group composed of disability examiners and a physician. All the evidence
in your case has been carefully evaluated; this includes the medical evidence and
the additional information received since the original decision. On the basis of the
evidence and your statements, we find that the previous determinations were proper
under the law.
Fill
in:
-
1.
Widow's/widower's/surviving divorced wife's/surviving divorced husband's
|
501(B).
|
DWB AND DIB — AFFIRMATION OF DENIAL, CESSATION OR ONSET DATE — STATE — PHYSICIAN PARTICIPATION
Upon receipt of your request for reconsideration, we had your claims for disabled
1 benefits and disability insurance benefits re-evaluated by a physician and a disability
examiner in the State agency which works with us in making disability determinations.
All the evidence in your case has been carefully evaluated; this includes the medical
evidence and the additional information received since the original decision. This
new evaluation was then independently reviewed in the Social Security Administration.
On the basis of the evidence and your statements, we have determined that the previous
determinations were proper under the law.
Fill
in:
-
1.
Widow's/widower's/surviving divorced wife's/surviving divorced husband's
|
504.
|
DIB OR FREEZE AFFIRMATION OF DENIAL, CESSATION OR ONSET DATE — NON-STATE NO PHYSICIAN
PARTICIPATION
Upon receipt of your request for reconsideration, we had your claim independently
reviewed by a special group. All the evidence in your case has been carefully evaluated;
this includes the medical evidence and the additional information received since the
original decision. On the basis of the evidence, and considering your age, education,
training, and work experience, we find that the previous determination was proper
under the law.
|
504(A).
|
DIB OR FREEZE — AFFIRMATION OF DENIAL, CESSATION OR ONSET DATE — NON-STATE — PHYSICIAN
PARTICIPATION
Upon receipt of your request for reconsideration, we had your claim independently
reviewed by a specially designated group composed of disability examiners and a physician.
All the evidence in your case has been carefully evaluated; this includes the medical
evidence and the additional information received since the original decision. On the
basis of the evidence, and considering your age, education, training and work experience,
we find that the previous determination was proper under the law.
|
504(B).
|
DIB OR FREEZE — AFFIRMATION OF DENIAL, CESSATION OR ONSET DATE — STATE — PHYSICIAN
PARTICIPATION
Upon receipt of your request for reconsideration, we had your claim re-evaluated by
a physician and a disability examiner in the State agency which works with us in making
disability determinations. All the evidence in your case has been carefully evaluated;
this includes the medical evidence and the additional information received since the
original decision. This new evaluation was then independently reviewed in the Social
Security Administration. On the basis of the evidence, and considering your age, education,
training and work experience, we have determined that the previous determination was
proper under the law.
|
505.
|
CDB — AFFIRMATION OF DENIAL OR CESSATION — NON-STATE — NO PHYSICIAN PARTICIPATION
Upon receipt of the request for reconsideration we had the claim for childhood disability
benefits independently reviewed by a special group. All the evidence in the case has
been carefully evaluated; this includes the medical evidence and the additional information
received since the original decision. On the basis of the evidence, and considering
the claimant's education and training, we find that the previous determination was
proper under the law.
|
505(A).
|
CDB — AFFIRMATION OF DENIAL OR CESSATION — NON STATE — PHYSICIAN PARTICIPATION
Upon receipt of the request for reconsideration, we had the claim for childhood disability
benefits independently reviewed by a specially designated group composed of disability
examiners and a physician. All the evidence in the case has been carefully evaluated;
this includes the medical evidence and the additional information received since the
original decision. On the basis of the evidence, and considering the claimant's education
and training, we find that the previous determination was proper under the law.
|
505(B).
|
CDB — AFFIRMATION OF DENIAL OR CESSATION — STATE — PHYSICIAN PARTICIPATION
Upon receipt of the request for reconsideration, we had the claim for childhood disability
benefits reevaluated by a physician and disability examiner in the State agency which
works with us in making disability determinations. All the evidence in the case has
been carefully evaluated; this includes the medical evidence and the additional information
received since the original decision. This new evaluation was then independently reviewed
in the Social Security Administration. On the basis of the evidence and considering
the claimant's education and training, we have determined that the previous determination
was proper under the law.
NOTE: Where a child has filed on his own behalf and one of the paragraphs 505, 505A, or
505B is used in the notice, change the language in the paragraph to the second person.
|
508.
|
DIB, DWB AND CDB - PARTIALLY FAVORABLE INITIAL ALLOWANCE TO A RECONSIDERATION DENIAL
Upon receipt of your request for reconsideration, we had your claim independently
reviewed by a special team composed of a disability examiner and a medical consultant(s).
The team carefully evaluated all of the evidence in your case, including the medical
evidence from our original decision and any new information we received after that
decision. Based on this evidence, we find that the previous determination was improper
under the law. We have changed our original decision and determined that you have
not been “disabled” within the meaning of the law at any time relevant to your application.
|
510.
|
DIB — NOT DISABLED — GENERAL
To be considered disabled for Social Security purposes you must have a medical condition
which prevents you from doing not only your usual work but also any other type of
substantial gainful activity.
|
511.
|
DIB — NOT DISABLED — EARNINGS TEST HAS EXPIRED OR WILL EXPIRE IN OR BEFORE THE QUARTER
FOLLOWING THE DATE THE LETTER IS PREPARED.
To be considered disabled for Social Security purposes you must have a medical condition
which prevents you from doing not only your usual work but also any other type of
substantial gainful activity. In addition, the disability must exist at a time when
another requirement called the earnings requirement is met. Your Social Security record
at the time of your application showed that you 1 this requirement on 2.
Fill
ins:
-
-
2.
MM/DD/YY (date last insured)
|
512.
|
DIB — NOT DISABLED WHEN EARNINGS TEST LAST MET — AOD BEFORE AGE 24
To be considered disabled for Social Security purposes you must have a medical condition
which prevents you from doing not only your usual work but also any other type of
substantial gainful activity. This inability to work must exist at a time when another
requirement called the earnings requirement is met.
A person whose disability began before age 24 must have Social Security credits for
6 calendar quarters (1 1/2 years) of work during a 12-quarter (3 year) period ending
with a quarter before age 24 in which he/she is disabled. Your Social Security record
shows that you last met this earnings requirement on 1. For you to qualify for benefits, your disability must have begun on or before that
date.
Fill
in:
-
1.
MM/DD/YY (date last insured)
|
512.1.
|
DIB — NOT DISABLED WHEN EARNINGS TEST LAST MET — AOD BETWEEN AGES 24-31
To be considered disabled for Social Security purposes you must have a medical condition
which prevents you from doing not only your usual work but also any other type of
substantial gainful activity. This inability to work must exist at a time when another
requirement called the earnings requirement is met.
A person whose disability began between the ages 24 and 31 must have Social Security
credits for work in at least one-half the calendar quarters in the period beginning
with the calendar quarter after age 21 and ending with a quarter before age 31 in
which he/she is disabled. Your Social Security record shows that you last met this
earnings requirement on 1. For you to qualify for benefits your disability must have begun on or before that
date.
Fill
in:
-
|
512.2.
|
DIB NOT DISABLED WHEN EARNINGS TEST LAST MET — AOD AT OR AFTER AGE 31 — (Disability
Not Due to Statutory Blindness)
To be considered disabled for Social Security purposes, a person must have a medical
condition which prevents him/her from doing not only his/her usual work but also any
other type of substantial gainful activity. This inability to work must exist at a
time when another requirement called the earnings requirement is met.
A person whose disability began at age 31 or later needs to meet two provisions of
the earnings requirement. First, he/she needs credit for 20 calendar quarters (5 years)
of work during a 40-quarter period (10 years) ending in or after a quarter in which
he/she is disabled. And second, he/ she needs credit for one calendar quarter of work
for each year after 1950 (or after reaching age 21, if this is later) up to the year
the disability began. In the second instance, the credits may have been earned at
any time.
|
520.
|
DIB — EXPLANATION OF DISABILITY REQUIREMENT
To be considered disabled for Social Security purposes a person must be unable to
engage in any substantial gainful activity due to a medical condition which has lasted
or can be expected to last for a continuous period of at least 12 months. His/Her
impairment must be so severe as to prevent him /her from engaging not only in his/her
usual occupation but also in any other kind of substantial gainful work, considering
his/her age, education, and work experience. This inability to work must exist at
a time when another requirement called the earnings requirement is met.
|
520.1.
|
DIB — EXPLANATION OF DISABILITY REQUIREMENT — EARNINGS TEST NOT EXPIRED
To be considered disabled for Social Security purposes a person must be unable to
engage in any substantial gainful activity due to a medical condition which has lasted
or can be expected to last for a continuous period of at least 12 months. His/Her
impairment must be so severe as to prevent him /her from engaging not only in his/her
usual occupation but also in any other kind of substantial gainful work considering
his/her age, education, and work experience. This inability to work must exist at
a time when another requirement called the earnings requirement is met. Your Social
Security record shows that you meet this earnings requirement until 1.
Fill
in:
-
1.
MM/DD/YY (date last insured)
|
520.2.
|
DIB — EXPLANATION OF DISABILITY REQUIREMENT — EARNINGS TEST EXPIRED — ADD BEFORE AGE
24
To be considered disabled for Social Security purposes a person must be unable to
engage in any substantial gainful activity due to a medical condition which has lasted
or can be expected to last for a continuous period of at least 12 months. His/Her
impairment must be so severe as to prevent him /her from engaging not only in his/her
usual occupation but also in any other kind of substantial gainful work, considering
his/her age, education and work experience. This inability to work must exist at a
time when the earnings requirement is met.
A person whose disability began before age 24 must have Social Security credits for
6 calendar quarters (1 1/2 years) of work during a 12-quarter (3 year) period ending
with a quarter before age 24 in which he/she is disabled. Your Social Security record
shows you last met the earnings requirement on 1.
Fill
in:
-
1.
MM/DD/YY (date last insured)
|
520.3.
|
DIB-EXPLANATION OF DISABILITY REQUIREMENT-EARNINGS TEST EXPIRED-AOD BETWEEN AGES 24-31
To be considered disabled for Social Security purposes a person must be unable to
engage in any substantial gainful activity due to a medical condition which has lasted
or can be expected to last for a continuous period of at least 12 months. His/Her
impairment must be so severe as to prevent him /her from engaging not only in his/her
usual occupation but also in any other kind of substantial gainful work, considering
his/her age, education and work experience. This inability to work must exist at a
time when the earnings requirement is met.
A person whose disability began between the ages 24 and 31 must have Social Security
credits for work in at least one-half the calendar quarters in the period beginning
with the calendar quarter after age 21 and ending with a quarter before age 31 in
which he/she is disabled. Your Social Security record shows you last met the earnings
requirement on 1.
Fill
in:
-
1.
MM/DD/YY (date last insured)
|
520.4.
|
DIB - EXPLANATION OF DISABILITY REQUIREMENT - EARNINGS TEST EXPIRED - AOD AT OR AFTER
AGE 31
(Disability Not Due to Statutory Blindness)
To be considered disabled for Social Security purposes a person must be unable to
engage in any substantial gainful activity due to a medical condition which has lasted
or can be expected to last for a continuous period of at least 12 months. His/Her
impairment must be so severe as to prevent him /her from engaging not only in his/her
usual occupation but also in any other kind of substantial gainful work, considering
his/her age, education and work experience. This inability to work must exist at a
time when the earnings requirement is met.
A person whose disability began at age 31 or later needs to meet two provisions of
the earnings requirement. First, he/she needs credit for 20 calendar quarters (5 years)
of work during a 40-quarter period (10 years) ending in or after a quarter in which
he/she is disabled. And second, he/she needs credit for one calendar quarter to work
for each year after 1950 (or after reaching age 21, if that is later) up to the year
his/her disability began. In the second instance, the credits may have been earned
at any time.
Your Social Security record shows you last met the earnings requirement on 1.
Fill
in:
-
1.
MM/DD/YY (date last insured)
|
521.
|
DIB - DISABLED IN QUARTER ALLEGED OR ONSET ESTABLISHED LATER THAN ALLEGED - EARNINGS
REQUIREMENT NOT MET - EOD BEFORE AGE 24
To meet the earnings requirement a person whose disability began before age 24 must
have Social Security credits for 6 calendar quarters (1 1/2 years) of work during
a 12-quarter (3-year) period ending with a quarter before age 24 in which he/she is
disabled.
After careful review it has been determined that your condition first prevented you
from doing substantial gainful work on 1. However, your Social Security record shows that you do not meet the earnings requirement
at that time or at any later date. You have earned credits for only 2 calendar quarters in the period ending 3.
Fill
ins:
-
-
-
|
521(A).
|
DIB - DISABLED IN QUARTER ALLEGED OR ONSET ESTABLISHED LATER THAN ALLEGED - EARNINGS
REQUIREMENT NOT MET - EOD BETWEEN THE AGES 24-31
To meet the earnings requirement, a person whose disability began between the ages
24 and 31 must have Social Security credits for work in at least one-half the calendar
quarters in the period beginning with the calendar quarter after age 21 and ending
with a quarter before age 31 in which he/she is disabled.
After careful review we have determined that your condition first prevented you from
doing substantial gainful work on 1. However, your Social Security record shows that you do not meet the earnings requirement
at that time or at any later date. You have earned credits for only 2 calendar quarters in the period ending 3.
Fill
ins:
-
-
-
|
521(B).
|
DISABLED IN QUARTER ALLEGED OR ONSET ESTABLISHED LATER THAN ALLEGED - EARNINGS REQUIREMENT
NOT MET - EOD AT OR AFTER AGE 31-(Disability Not Due to Statutory Blindness)
To meet the earnings requirement, a person whose disability began at age 31 or later
must meet two provisions of the law. First, he/she needs credit for 20 calendar quarters
(5 years) of work during a 40-quarter period (10 years) ending in or after a quarter
in which he/she is disabled. And second, he/ she needs credit for one calendar quarter
of work for each year after 1950 (or after reaching age 21, if that is later) up to
the year his/her disability began. In the second instance, the credits may have been
earned at any time.
After carefully studying your records and the medical evidence, we have determined
that your condition first prevented you from doing substantial gainful work on 1. However, you do not meet the earnings requirement at that time or at any later time.
You need a total of 2 Social Security credits as of this date. Your Social Security record shows that you
have 3 credits in the 40-quarter period ending with the calendar quarter you became disabled
and (a total of) (at least) 4 credits as of that time.
Fill
ins:
-
-
-
-
|
521.1.
|
DIB - NOT DISABLED IN AOD OR AT ANY TIME THEREAFTER UP TO AND INCLUDING LAST QUARTER
IN WHICH EARNINGS REQUIREMENT MET - AOD BEFORE AGE 24
To meet the earnings requirement a person whose disability began before age 24 must
have Social Security credits for 6 calendar quarters (1 1/2 years) of work during
a 12-quarter (3-year) period ending with a quarter before age 24 in which he/she is
disabled.
After careful review we have determined that your condition was not disabling within
the meaning of the law on 1 (the date you state you became unable to work) or any later date through 2. This is the last day on which you still met the earnings requirement.
Fill
ins:
-
-
|
521.11.
|
DIB - NOT DISABLED IN AOD OR AT ANY TIME THEREAFTER UP TO AND INCLUDING LAST QUARTER
IN WHICH EARNINGS REQUIREMENT MET - AOD BETWEEN AGES 24-31
To meet the earnings requirement, a person whose disability began between the ages
24 and 31 must have Social Security credits for work in at least one-half the calendar
quarters in the period beginning with the calendar quarter after age 21 and ending
with a quarter before age 31 in which he/she is disabled.
After careful review we have determined that your condition was not disabling within
the meaning of the law on 1 (the date you state you became unable to work) or any later date through 2. This is the last day on which you still met the earnings requirement.
Fill
ins:
-
-
|
521.12.
|
DIB - NOT DISABLED IN AOD OR AT ANY TIME THEREAFTER UP TO AND INCLUDING LAST QUARTER
IN WHICH EARNINGS REQUIREMENT MET - AOD AT OR AFTER AGE 31 (Disability Not Due to
Statutory Blindness)
To meet the earnings requirement a person whose disability began at age 31 or later
must meet two provisions of the law. First, he/she needs credit for 20 calendar quarters
(5 years) or work during a 40-quarter period (10 years) ending in or after a quarter
in which he/she is disabled. And second, he/ she needs credit for one calendar quarter
of work for each year after 1950 (or after reaching age 21, if that is later) up to
the year his/her disability began. In the second instance, the credits may have been
earned at any time. After careful review we have determined that your condition was
not disabling within the meaning of the law on 1 (the date you state you became unable to work) or any later date through 2. This is the last day on which you still met the earnings requirement.
Fill
ins:
-
-
|
521.20.
|
DIB - NOT DISABLED AT ANY TIME EARNINGS REQUIREMENT MET - AOD BEFORE AGE 24
To meet the earnings requirement a person whose disability began before age 24 must
have Social Security credits for 6 calendar quarters (1 1/2 years) of work during
a 12 quarter (3 year) period ending with a quarter before age 24 in which he/she is
disabled.
After careful review we have determined that your condition was not disabling within
the meaning of the law on any date through 1. This is the last day on which you still met the earnings requirement.
Fill
in:
-
1.
MM/DD/YY (date last insured)
|
521.21.
|
DIB - NOT DISABLED AT ANY TIME EARNINGS REQUIREMENT MET - AOD BETWEEN THE AGES 24-31
To meet the earnings requirement, a person whose disability began between the ages
24 and 31 must have Social Security credits for work in at least one-half the calendar
quarters in the period beginning with the calendar quarter after age 21 and ending
with a quarter before age 31 in which he/she is disabled.
After careful review we have determined that your condition was not disabling within
the meaning of the law on any date through 1. This is the last day on which you still met the earnings requirement.
Fill
in:
-
1.
MM/DD/YY (date last insured)
|
521.22.
|
DIB - NOT DISABLED AT ANY TIME EARNINGS REQUIREMENT MET - AOD AT OR AFTER AGE 31
(Disability Not Due to Statutory Blindness)
To meet the earnings requirement, a person whose disability began at age 31 or later
needs to meet two provisions of the law. First, he/she needs credit for 20 calendar
quarters (5 years) of work during a 40-quarter period (10 years) ending in or after
a quarter in which he/she is disabled. And second, he/she needs credit for one calendar
quarter of work for each year after 1950 (or after reaching age 21, if that is later)
up to the year his/her disability began. In the second instance, the credits may have
been earned at any time.
After careful review we have determined that your condition was not disabling within
the meaning of the law on any date through 1. This is the last day on which you still met the earnings requirement.
Fill
in:
-
1.
MM/DD/YY (date last insured)
|
521.23.
|
STATUTORY BLINDNESS - NOT DISABLED AT ANY TIME EARNINGS REQUIREMENT MET - AOD 1973
OR LATER
To meet the earnings requirement of the law, a person whose disability is due to statutory
blindness must have one Social Security credit for each year elapsing after 1950 (or
after age 21, if that is later) up to the year he/ she became disabled. A minimum
of 6 credits is needed. The credits may have been earned at any time during the person's
employment under Social Security coverage.
After careful review we have determined that your condition was not disabling within
the meaning of the law on any date through 1. This is the last date on which you still met the earnings requirement.
Fill
in:
-
1.
MM/DD/YY (date last insured)
|
521.24.
|
STATUTORY BLINDNESS (1972 Amendments) NOT INSURED AT AOD - AOD 1973 OR LATER
To meet the earnings requirement of the law, a person whose disability is due to statutory
blindness must have one Social Security credit for each year elapsing after 1950 (or
after age 21, if that is later) up to the year he/ she became disabled. A minimum
of 6 credits is needed. The credits may have been earned at any time during the person's
employment under Social Security coverage.
You state that you became disabled on 1. Therefore, you need 2 credits to meet the earnings requirement. Your earnings record shows that you have
only 3 credits. Since you do not meet the earnings requirement, it has not been necessary
to determine whether or not you are disabled.
Fill
ins:
-
-
-
|
521.25.
|
STATUTORY BLINDNESS - NOT DISABLED WHEN EARNINGS REQUIREMENT TEST LAST MET - AOD BEFORE
1973
Before the 1972 amendments to the Social Security Act, a disabled person needed to
meet two provisions of the earnings requirement. First he/she needed 20 Social Security
credits in the 40 quarter (10 year) period ending in or after the quarter in which
he/she became disabled. Second, he/she needed one Social Security credit for each
year elapsing after 1950 (or after the attainment of age 21, if that is later) up
to the year he/she became disabled. A minimum of 6 credits is needed. The credits
may have been earned at any time during the person's employment under Social Security
coverage. You last meet this requirement on 1.
Under the 1972 amendments only the second requirement must be met if disability is
due to statutory blindness. You last meet the second requirement 2. After careful review we have determined that you were not statutorily blind on or
before either of the above two dates.
Fill
ins:
-
1.
MM/DD/YY (date last insured)
-
2.
MM/YY (date last fully insured)
|
522.
|
CDB - EXPLANATION OF DISABILITY REQUIREMENT
To be considered disabled for Social Security purposes, a claimant for childhood disability
benefits must be unable to engage in any substantial gainful activity due to a medical
condition which has lasted or can be expected to last for a continuous period of at
least 12 months. This impairment must be so severe as to prevent him/her from engaging
in substantial gainful work, considering his/her education, and previous training.
Before the 1972 amendments to the Social Security Act, a claimant for childhood disability
benefits had to have a disability which began before he/ she was age 18. The 1972
amendments changed this requirement so that a person may qualify if his/her disability
began before age 22. The earliest date a person can be entitled under the 1972 law
is January 1973.
|
522.1.
|
CDB - DISABILITY MUST START BEFORE AGE 22
A child's disability, as defined by law, must start before age 22. Any medical condition
that may have become disabling after attainment of age 22 cannot serve as the basis
for qualifying under the disability provisions of the law.
|
522.2.
|
CDB - EXPLANATION OF CLAIMANT'S RIGHTS AFTER CESSATION
A person whose entitlement to childhood disability benefits has ended may again become
eligible for them if his/her physical or mental condition again becomes disabling
within 7 years after his/he prior entitlement to childhood disability benefits was
terminated. If you are again prevented by your condition from doing any kind of substantial
gainful work, contact any Social Security office about filing another disability application.
|
522.3.
|
CDB - 7-YEAR PERIOD FOR REENTITLEMENT ENDED BEFORE EOD
To qualify for childhood disability benefits, your condition must have been severe
enough to meet the disability requirement of the law within 7 years after your prior
entitlement to childhood disability benefits ended. After careful review we have determined
that your condition again became disabling on 1. However, the 7 year period in your case ended 2.
Fill
ins:
-
-
2.
Last day of the specified period
|
522.4.
|
CDB - NOT DISABLED AT AOD OR AT ANY TIME WITHIN 7-YEAR PERIOD AFTER END OF PRIOR ENTITLEMENT
To qualify for childhood disability benefits, your condition must have been severe
enough to meet the disability requirement of the law within 7 years after your prior
entitlement to childhood disability benefits ended. After careful review we have determined
that your condition was not severe enough to meet the disability requirement of the
law on 1, the date you state you became disabled, or on any later date before 2, the end of the 7-year period in your case.
Fill
ins:
-
-
2.
Last day of specified period
|
522.5.
|
CDB REENTITLEMENT - NOT DISABLED AT ANY TIME BEFORE 7-YEAR PERIOD ENDED
We have determined that your condition was not severe enough on any date before 1, the date your 7-year period ended.
Fill
in:
-
1.
Last day of specified period
|
522.6.
|
CDB REENTITLEMENT — DISABILITY MORE THAN 7 YEARS AFTER PRIOR PERIOD ENDED CANNOT SERVE
TO QUALIFY
A person cannot be entitled to childhood disability benefits based on a medical condition
which became disabling after the 7-year period ended.
|
522.7.
|
CDB — REENTITLEMENT — ADVICE REGARDING WORSENING OF CONDITION
If your condition gets worse before 1, the date your 7-year period ends, write, call or visit any Social Security office
about filing another application for childhood disability benefits.
Fill
in:
-
1.
Last day of specified period
|
523(A).
|
FREEZE CESSATION
The law provides that an individual's disability freeze period shall end if the person
is able to do substantial gainful work. The law also provides that an individual will
have a freeze period for the month disability ends and the following two months. The
medical evidence in your case shows that you became able to do substantial gainful
work in 1. Accordingly, the last month of your disability freeze is 2.
Fill
ins:
-
-
|
524.
|
DIB CESSATION — WORK ACTIVITY — TRIAL WORK PERIOD
To be considered disabled for Social Security purposes, a person's impairment must
be so severe as to prevent him/her from engaging not only in his/her usual occupation
but also in any other kind of substantial gainful work, considering his/her age, education
and work experience. Disability benefits end when a person is no longer disabled within
the meaning of the law. If a person works while still under a disability, his/her
benefit payments are continued during 9 months of work. (These months need not be
consecutive, and any work done in a month is counted as a month of work.) Then if
it is determined after the 9 months that he/she has demonstrated his/her ability to
do substantial gainful work and therefore is no longer disabled, his/her benefits
are paid for 3 more months.
|
524(A).
|
FREEZE CESSATION — WORK ACTIVITY
To be considered disabled for Social Security purposes, a person's impairment must
be so severe as to prevent him/her from engaging not only in his/her usual occupation
but also in any other kind of substantial gainful work, considering his/her age, education
and work experience. A disability freeze ends when a person is no longer disabled
within the meaning of the law. If a person with a disability freeze returns to work
and it is determined that the work is substantial gainful activity, the freeze will
be terminated. The law continues the freeze, however, for the month the disability
ends and the following two months.
|
524(B).
|
DIB CESSATION — WORK ACTIVITY — NO WAITING PERIOD SERVED
To be considered disabled for Social Security purposes, a person's impairment must
be so severe as to prevent him/her from engaging not only in his/her usual occupation
but also in any other kind of substantial gainful work, considering his/her age, education
and work experience. The law provides that a person who has a severe impairment is
allowed a trial work period in which he/she may work in 9 months before a decision
is made as to whether his/her benefits should be continued. However, the trial work
period does not apply when a person who had a prior period of disability again becomes
entitled to disability benefits without serving a waiting period. His /Her disability
ends when he/she returns to substantial gainful work. However, benefits will be paid
for the month disability ends and two additional months.
|
525(B).
|
CDB CESSATION — WORK ACTIVITY TWP PREVIOUSLY USED
To be considered disabled for Social Security purposes, a childhood disability beneficiary's
impairment must be so severe as to prevent him/her from engaging in any substantial
gainful activity, considering his/her previous training and education. Disability
benefits end when a person is no longer disabled within the meaning of the law. If
a childhood disability beneficiary works, his/her benefit payments are continued during
9 months of work. (These months need not be consecutive, and any work done in a month
is counted as a month of work.) If at the end of 9 months of work he/she still is
not able to engage in substantial gainful activity, his/her benefits will be continued.
Should he/she later perform work which is substantial gainful activity, he/she will
no longer be considered disabled and his/her disability benefits will be paid for
the month disability ends and two additional months.
|
525(C).
|
CDB DENIAL BEFORE AGE 22 — ADVICE REGARDING WORSENING OF CONDITION
If 1 condition gets worse and keeps 2 from doing any substantial gainful work before age 22, please contact any Social
Security office about filing another application.
Fill
ins:
-
-
|
530.
|
DIB OR FREEZE — TERMINATION DUE TO WORK ACTIVITY
The evidence shows that you returned to work on 1. After carefully reviewing all the facts in your case, we still find that the work
you have been doing since 2 is “substantial gainful activity” within the meaning of the law. Therefore, the determination
to end your disability period with the month of 3 is proper under the law. The disability period already established for you beginning
4 and ending 5 may still be used to your advantage in deciding whether benefits can be paid on your
Social Security record in the future, and in figuring the amount of such benefits.
Fill
ins:
-
-
-
-
-
|
533.
|
DIB OR FREEZE — DISABILITY MUST EXIST WHEN EARNINGS REQUIREMENT IS MET
The inability to engage in any type of substantial gainful activity because of a medical
condition must exist at a time when the earnings requirement is met.
|
533(A).
|
DIB OR FREEZE — DISABILITY AFTER EARNINGS REQUIREMENT LAST MET CANNOT SERVE TO QUALIFY
A medical condition which may have become disabling after the earnings requirement
is last met cannot serve as a basis for qualifying under the disability provisions
of the law.
|
533(B).
|
DIB OR FREEZE — CONDITION NOT SEVERE WHEN EARNINGS REQUIREMENT MET
The evidence does not show that your condition when you met the earnings requirement,
affected your ability so much as to keep you from doing some type of gainful work
at that time. A medical condition which may have become disabling after the earnings
requirement is last met cannot serve as a basis for qualifying under the disability
provisions.
|
534.
|
DIB OR FREEZE — DISABILITY MUST START AT LEAST 5 MONTHS BEFORE FULL RETIREMENT AGE
The continuous inability to engage in any type of substantial gainful activity must
start at least 5 months before the month of reaching FULL RETIREMENT AGE.
|
534(A).
|
DIB OR FREEZE
Any medical condition that may have become disabling less than 5 months before the
month of reaching full retirement age cannot serve as the basis for qualifying under
the disability provisions of the law.
|
535.
|
DIB OR FREEZE — DISABILITY MUST START AT LEAST 5 MONTHS BEFORE THE MONTH OF ATTAINING
FULL RETIREMENT AGE AND WHEN EARNINGS REQUIREMENT IS MET
Although you may now be unable to do any work because of your medical condition, that
alone does not make you eligible. Under the law, the continuous inability to engage
in any type of substantial gainful activity must start at least 5 months before the
month of reaching full retirement age and at a time when the earnings requirement
is met.
|
536.
|
DEFINITION OF SGA
Substantial gainful work is any work generally performed for remuneration or profit,
involving the performance of significant physical or mental duties. Work may be considered
substantial even if performed part-time. In evaluating a person's work activity, consideration
is given to such factors as the nature of the job duties and the skill and experience
required to do the job, in addition to his/her earnings. The fact that his/her current
work may be different, less complex and less gainful than that which he/she did before
his/her disability began does not necessarily mean that he/she will still be considered
eligible for benefits under the terms of the law. Under the Social Security regulations
when a person's earnings average more than 1, he/she is generally considered to be performing substantial gainful work.
Fill
in:
-
|
541.
|
DIB OR FREEZE — MEETING EARNINGS REQUIREMENT AFTER ONSET DATE
If a person does not have enough Social Security credits to meet the earnings requirement
at the time he/she became disabled, he/she may still satisfy this provision of the
law if he/she later obtains the necessary credits.
|
542.
|
DIB OR FREEZE — DATE EARNINGS REQUIREMENT WAS LAST MET
Your Social Security record shows that you last met the earnings requirement on 1.
Fill
in:
-
1.
MM/YY (date earnings requirement last met)
|
543.
|
DIB OR FREEZE — CLAIMANT AGED 62-65 — POSSIBLE ENTITLEMENT TO REDUCED RIB
Although you do not now qualify for disability insurance benefits or the disability
“freeze”, our records show you have enough credit for work under Social Security to
qualify for retirement benefits. The Social Security Act provides that retired workers
may qualify for retirement benefits starting at age 62. If they choose to receive
them before they become 65, however, the amount of the benefit is reduced. If you
would like further information about this, we suggest you get in touch with any Social
Security office. The staff there will be glad to discuss your eligibility with you
and help you apply for benefits if you wish to do so.
|
544.
|
DIB OR FREEZE — NOT DISABLED — CLAIMANT WILL ATTAIN RETIREMENT AGE BEFORE EARNINGS
TEST EXPIRES
As you were previously informed, this determination concerns only your disability
application. It is not a decision as to whether benefits will be payable to you at
retirement age. If your condition should get worse, and prevent you from doing substantial
gainful work, you should get in touch with any Social Security office.
|
544(A).
|
DIB OR FREEZE — DETERMINATION CONCERNS ONLY DISABILITY APPLICATION
As you were previously informed, this determination concerns only your disability
application. It is not a decision as to whether benefits will be payable to you at
retirement age.
|
546.
|
DIB OR FREEZE — GENERAL DESCRIPTION OF EARNINGS REQUIREMENT
To meet the earnings requirement, a person whose disability began before age 24 must
have Social Security credits for 6 calendar quarters (1 1/2 years) of work during
a 12-quarter (3-year) period ending with a quarter before age 24 in which he/she is
disabled. If disability began between the ages of 24 and 31, he/she must have Social
Security credits for work in at least one-half the calendar quarters in the period
beginning with the calendar quarter after age 21 and ending with a quarter before
age 31 in which he/she is disabled. If disability began at age 31 or later, he/she
must meet two provisions of the earnings requirement.
First, he/she needs credit for 20 calendar quarters (5 years) of work during a 40-quarter
period (10-years) ending in or after a quarter in which he /she is disabled. And second,
he/she needs credit for one calendar quarter of work for each year after 1950 (or
after reaching age 21, if that is later) up to the year his/her disability began.
A minimum of 6 credits is always needed. In the second instance, the credits may have
been earned at any time.
|
546.1.
|
DIB OR FREEZE — DESCRIPTION OF 6/12 TEST — DISABILITY BEFORE AGE 24
To meet the earnings requirement a person whose disability began before age 24 must
have Social Security credits for 6 calendar quarters (1 1/2 years) of work during
a 12-quarter (3-year) period ending with a quarter before age 24 in which he/she is
disabled.
|
546.2.
|
DIB OR FREEZE — DESCRIPTION OF EARNINGS REQUIREMENT — DISABILITY BETWEEN THE AGES
24-31
To meet the earnings requirement, a person whose disability began between the ages
24 and 31 must have Social Security credits for work in at least one-half the calendar
quarters in the period beginning with the calendar quarter after age 21 and ending
with a quarter before age 31 in which he/she is disabled.
|
546.3.
|
DIB OR FREEZE — DESCRIPTION OF EARNINGS REQUIREMENT — DISABILITY AT AGE 31 OR LATER
To meet the earnings requirement, a person whose disability began at age 31 or later
must meet two provisions of the law. First, he/she needs credit for 20 calendar quarters
(5 years) of work during a 40-quarter period (10 years) ending in or after a quarter
in which he/she is disabled. And second, he/ she needs credits for one calendar quarter
of work for each year after 1950 (or after reaching age 21, if that is later) up to
the year his/her disability began. In the second instance, the credits may have been
earned at any time.
|
547.
|
DESCRIPTION OF EARNINGS REQUIREMENT — STATUTORY BLINDNESS — AOD 1973 OR LATER
To meet the earnings requirement of the law a person whose disability is due to statutory
blindness must have one Social Security credit for each year elapsing after 1950 (or
after age 21, if that is later) up to the year he/ she became disabled. A minimum
of 6 credits is needed. The credits may have been earned at any time during the person's
employment under Social Security coverage.
|
548.
|
DESCRIPTION OF OLD AND NEW EARNINGS REQUIREMENT — STATUTORY BLINDNESS
Before the 1972 amendments to the Social Security Act, a disabled person needed to
meet two provisions of the earnings requirement. First, he/she needed 20 Social Security
credits in the 40 quarter (10 years) period ending in or after the quarter in which
he/she became disabled. Second, he/she needed one Social Security credit for each
year elapsing after 1950 (or after the attainment of age 21, if that is later) up
to the year he/she became disabled. A minimum of 6 credits is needed. The credits
may have been earned at any time during the person's employment under Social Security
coverage.
Under the 1972 amendments only the second requirement must be met if disability is
due to statutory blindness.
|
549.
|
DIB ALLOWANCE UNDER 1972 AMENDMENTS — STATUTORY BLINDNESS
Before the 1972 amendments to the Social Security Act, a disabled person needed to
meet two provisions of the earnings requirement. First, he/she needed one Social Security
credit for each year elapsing after 1950 (or after attainment of age 21, if that is
later) up to the year he/she became disabled. Second, he/she needed 20 Social Security
credits in the 40 quarter (10 year) period ending in or after the quarter in which
he/she became disabled. Although you meet the first provision, your Social Security
record shows that you have only 1 credits in the 40 quarter period ending 2, the last day of the calendar quarter in which you became disabled. Therefore, you
do not meet the earnings requirement in effect before the 1972 amendments.
Under the 1972 amendments, only the first provision of the law must be met by a person
disabled because of statutory blindness. Since you meet this requirement, you are
entitled to disability insurance benefits beginning 3. This is the earliest date benefits can be paid under the 1972 amendments to the
Social Security Act.
Fill
ins:
-
-
-
|
550.
|
FAVORABLE DISABILITY DETERMINATION BY VETERANS ADMINISTRATION — GENERAL
The finding of the Veterans Administration in your case was carefully considered by
us along with the rest of the evidence in your file. The Veterans Administration has
several disability programs under different laws, and the eligibility requirements
differ in each instance. Although similar, the eligibility requirements under the
disability programs administered by the Veterans Administration and by the Social
Security Administration are not the same. Thus, a person who meets the requirements
under a Veterans Administration program does not necessarily qualify under the disability
provisions of the Social Security Act. Under our program we must determine whether
the requirements contained in the Social Security Act are met.
|
551.
|
P&T PENSION AWARD BY VETERANS ADMINISTRATION
The fact that you were found permanently and totally disabled under the Veterans Administration
program was carefully considered by us along with the rest of the evidence in your
case. A determination by the Veterans Administration that a person is permanently
and totally disabled does not necessarily mean that he will qualify under the disability
provisions of the Social Security Act. Although there are many similarities, the eligibility
requirements under the disability programs administered by the Veterans Administration
and by the Social Security Administration are not the same. Under our program we must
determine whether the requirements contained in the Social Security Act are met.
|
552.
|
DISABILITY BENEFITS BY OTHER THAN VETERANS ADMINISTRATION
The fact that you were found eligible by the (Workmen's Compensation) (Insurance Company)
to receive payment because of disability does not necessarily mean that you will be
considered disabled under the Social Security Act, since each disability program has
its own eligibility requirements. However, this matter has been carefully considered
by us along with the rest of the evidence in your case.
|
553.
|
PARTIAL ALLOWANCE IN FREEZE CASES (Will ordinarily be typed in form allowance notice)
Although you gave 1 as the date your condition began, the evidence in the file does not support this
date. We have determined from the evidence that you first became unable to engage
in any substantial gainful activity because of your condition on 2.
Fill
ins:
-
-
|
554.
|
CONCLUSION OF DISABILITY BY ATTENDING PHYSICIAN
In making the decision in this case very careful consideration was given to the conclusion
of your attending physician. We value the evidence received from an applicant's attending
physician very highly and are most reluctant to reach a decision which is not consistent
with his/her judgment. However, in our program an independent determination must be
made as to whether the person meets the requirements of the law and the regulations
on the basis of the clinical findings of all examining physicians, results of laboratory
studies, treatment given and response, as well as the individuals training and experience.
Where judgments differ as to the effects of impairments, the decision must be based
on the objective evidence presented.
|
555.
|
DIB EXPLANATION OF CLAIMANT'S RIGHTS AFTER CESSATION
A person whose disability freeze and disability benefit payments have ended may become
eligible for them again if his/her physical or mental condition again prevents him/her
from doing substantial gainful work. If you are again prevented by your condition
from doing any kind of substantial gainful work, contact any Social Security office
about filing another disability application. The disability freeze period already
established for you may still be used to your advantage in deciding whether future
benefits can be paid on your Social Security record and in figuring the amount of
such benefits.
|
556.
|
RECONSIDERATION AFFIRMATION LEAD-IN PARAGRAPH
We have reconsidered your claim and find that the previous determination was correct.
Your claim was independently reviewed by a physician and disability examiner in the
State agency which works with us in making disability determinations. All the evidence
in your case has been thoroughly evaluated; this includes the medical evidence and
the additional information received since the original decision.
|
570.
|
DWB — AFFIRMATION OF DENIAL CESSATION OR ONSET DATE — NON-STATE — NO PHYSICIAN PARTICIPATION
Upon receipt of your request for reconsideration, we had your claim independently
reviewed by a special group. All the evidence in your case has been carefully evaluated;
this includes the medical evidence and the additional information received since the
original decision. On the basis of the evidence and your statements, we find that
the previous determination was proper under the law.
|
570.1.
|
DWB — AFFIRMATION OF DENIAL, CESSATION OR ONSET DATE — NON STATE — PHYSICIAN PARTICIPATION
Upon receipt of your request for reconsideration, we had your claim independently
reviewed by a specially designated group composed of disability examiners and a physician.
All the evidence in your case has been carefully evaluated; this includes the medical
evidence and the additional information received since the original decision. On the
basis of the evidence and your statements, we find that the previous determination
was proper under the law.
|
570.2.
|
DWB — AFFIRMATION OF DENIAL, CESSATION OR ONSET DATE — STATE — PHYSICIAN PARTICIPATION
Upon receipt of your request for reconsideration, we had your claim re-evaluated by
a physician and a disability examiner in the State agency which works with us in making
disability determinations. All the evidence in your case has been carefully evaluated;
this includes the medical evidence and the additional information received since the
original decision. This new evaluation was then independently reviewed in the Social
Security Administration. On the basis of the evidence, and your statements, it has
been determined that the previous determination was proper under the law.
|
572.
|
DWB — EXPLANATION OF DISABILITY REQUIREMENT (WIDOW)
A widow may be considered disabled only if she has a physical or mental impairment
that is so severe as to ordinarily prevent a person from working. In addition her
disability must have lasted or be expected to last for a continuous period of at least
12 months.
|
572.1.
|
DWB - EXPLANATION OF DISABILITY REQUIREMENT (WIDOWER)
A widower may be considered disabled only if he has a physical or mental impairment
that is so severe as to ordinarily prevent a person from working. In addition, his
disability must have lasted or be expected to last for a continuous period of at least
12 months.
|
572.2.
|
DWB - EXPLANATION OF DISABILITY REQUIREMENT (SURVIVING DIVORCED WIFE)
A surviving divorced wife may be considered disabled only if she has a physical or
mental impairment that is so severe as to ordinarily prevent a person from working.
In addition, her disability must have lasted or be expected to last for a continuous
period of at least 12 months.
|
573.
|
DWB - EXPLANATION OF SPECIFIED 7-YEAR PERIOD (WIDOW)
To qualify for disability benefits, a widow (age 50-60) must meet the disability requirement
within a specified period of time. Her disability must start not later than 7 years
after the death of her husband. Or, for a widow formerly entitled to mother's benefits
or disabled widow's benefits, the disability must start not later than 7 years after
those benefits ended.
|
573.1.
|
DWB - EXPLANATION OF SPECIFIED 7-YEAR PERIOD (WIDOWER)
To qualify for disability benefits, a dependent widower (age 50-60) must meet the
disability requirement within a specified period of time. His disability must start
no later than 7 years after the death of his wife. Or, for a widower formerly entitled
to disabled widower's benefits who becomes disabled again, the disability must start
not later than 7 years after those benefits ended.
|
573.2.
|
DWB - EXPLANATION OF SPECIFIED 7-YEAR PERIOD (SURVIVING DIVORCED WIFE)
To qualify for disability benefits, a surviving divorced wife (age 50-60) must meet
the disability requirements within a specified period of time. Her disability must
start not later than 7 years after the death of the spouse. Or, for a surviving divorced
wife formerly entitled to mother's benefits or disabled widow's benefits, the disability
must start not later than 7 years after those benefits ended.
|
575.
|
DWB - DATE SPECIFIED PRESCRIBED PERIOD LAST MET
The last day of the prescribed period is 1.
Fill
in:
-
|
575.3.
|
DWB-7-YEAR PERIOD ENDED BEFORE EOD
To qualify for disability benefits your condition must be severe enough to meet the
disability requirement of the law before the end of the specified 7-year period. After
careful review it has been determined that your condition first became disabling on
1. However, the 7-year period in your case ended 2.
Fill
ins:
-
-
2.
Last day of specified period
|
575.5.
|
DWB — NOT DISABLED AT AOD OR AT ANY TIME WITHIN 7-YEAR PERIOD
To qualify for disability benefits, your condition must have been severe enough to
meet the disability requirements of the law before the end of the specified 7-year
period. After careful review it has been determined that your condition was not severe
enough to meet the disability requirement of the law on 1 (the date you state you became disabled), or on any later date before 2 (the last day of the specified 7-year period in your case).
Fill
ins:
-
-
2.
Last day of specified period
|
576.
|
DWB CESSATION-MEDICAL IMPROVEMENT — WIDOW
To be considered disabled for Social Security purposes, a widow must have an impairment
that is so severe as to ordinarily prevent a person from working. Disability benefits
end when this requirement is no longer met. The law continues her benefits, however,
for 2 months after the month in which her condition improved to the extent that it
no longer prevents her from working.
|
576.1.
|
DWB CESSATION — MEDICAL IMPROVEMENT — WIDOWER
To be considered disabled for Social Security purposes, a widower must have an impairment
that is so severe as to ordinarily prevent a person from working. Disability benefits
end when this requirement is no longer met. The law continues his benefits, however,
for 2 months after the month in which his condition improved to the extent that it
no longer prevents him from working.
|
576.2.
|
DWB CESSATION — MEDICAL IMPROVEMENT — SURVIVING DIVORCED WIFE
To be considered disabled for Social Security purposes, a surviving divorced wife
must have an impairment that is so severe as to ordinarily prevent a person from working.
Disability benefits end when this requirement is no longer met. The law continues
her benefits, however, for 2 months after the month in which her condition improved
to the extent that it no longer prevents her from working.
|
576.3.
|
DWB CESSATION WORK ACTIVITY — WIDOW
To be considered disabled for Social Security purposes, a widow must have an impairment
that is so severe as to ordinarily prevent a person from working. Disability benefits
end when a person is no longer disabled within the meaning of the law. The law continues
her benefits, however, for 2 months after the month in which it is determined that
she engaged in substantial gainful work.
|
576.4.
|
DWB CESSATION — WORK ACTIVITY — WIDOWER
To be considered disabled for Social Security purposes, a widower must have an impairment
that is so severe as to ordinarily prevent a person from working. Disability benefits
end when a person is no longer disabled within the meaning of the law. The law continues
his benefits, however, for 2 months after the month in which it is determined that
he engaged in substantial gainful work.
|
576.5.
|
DWB CESSATION — WORK ACTIVITY — SURVIVING DIVORCED WIFE
To be considered disabled for Social Security purposes, a surviving divorced wife
must have an impairment that is so severe as to ordinarily prevent a person from working.
Disability benefits end when a person is no longer disabled within the meaning of
the law. The law continues her benefits, however, for 2 months after the month in
which it is determined that she engaged in substantial gainful work.
|
577.
|
DWB — DISABILITY MUST EXIST WHEN SPECIFIED 7-YEAR PERIOD REQUIREMENT MET
A person is eligible for disability benefits if the physical or mental impairment
is severe enough to meet the disability requirement of the law on or before the last
day of the specified 7-year period.
|
577.1.
|
DWB — DISABILITY AFTER SPECIFIED 7-YEAR PERIOD CANNOT SERVE TO QUALIFY
A medical condition which may have become disabling after the end of the specified
7-year period cannot serve as a basis for qualifying under the disability provisions
of the law.
|
577.2.
|
DWB — CONDITION NOT SEVERE WHEN SPECIFIED 7-YEAR REQUIREMENT LAST MET
The evidence does not show that your condition was severe enough to meet the disability
requirement of the law before the end of the specified 7-year period in your case.
A medical condition which may have become disabling after the end of the 7-year period
cannot serve as a basis for qualifying under the disability provisions of the Social
Security Act.
|
578.
|
DWB — DISABILITY MUST START AT LEAST 6 MONTHS BEFORE AGE 60 — WIDOW
A widow's disability, as defined by law, must start at least 6 full calendar months
before the month of reaching age 60.
|
578.1
|
DWB — DISABILITY THAT STARTS LESS THAN 5 MONTHS BEFORE AGE 60 CANNOT SERVE TO QUALIFY
— WIDOW
Any medical condition of a widow that may have become disabling less than 6 full calendar
months before the month of reaching age 60 cannot serve as the basis for qualifying
under the disability provisions of the law.
|
578.2.
|
DWB — DISABILITY MUST START AT LEAST 6 MONTHS BEFORE AGE 60 — WIDOWER
A widower's disability, as defined by law must start at least 6 full calendar months
before the month of reaching age 60.
|
578.3.
|
DWB — DISABILITY THAT STARTS LESS THAN 5 MONTHS BEFORE AGE 60 CANNOT SERVE TO QUALIFY
— WIDOWER
Any medical condition of a widower that may have become disabling less than 6 full
calendar months before the month of reaching age 60 cannot serve as the basis for
qualifying under the disability provisions of the law.
|
585.
|
ESCALATED TO RECONSIDERATION LEVEL TITLE II CLAIM
Because you had already requested a reconsideration on your Supplemental Security
Income claim when you filed for Social Security disability benefits, we processed
your Social Security claim as though you had requested a reconsideration on it as
well. This notice is both an initial and a reconsideration determination.
|
586.
|
COMBINED INITIAL-RECONSIDERATION DETERMINATION
You asked us to reconsider your 1 claim before we had given you our initial determination on that claim. This notice
includes our initial determination and the reconsideration determination on your claim.
Fill
in:
-
|
587.
|
ESCALATED TITLE II CLAIM — OTHER TITLE II CLAIM AT RECONSIDERATION LEVEL
You asked us to reconsider your 1 claim before we had given you our initial determination on your 2 claim. We processed your 2 claim as if you had requested reconsideration on it. This notice includes our initial
and reconsideration determination on your 2 claim.
Fill
ins:
-
1.
Claim at reconsideration level
-
|
600.
|
SUSPENSION OF PAYMENT TO CHILD(REN) — W/E EMPLOYED
No benefits can be paid to you for the use of your child(ren) until you send in the
Form SSA-1425-SM, Claimant's Report About Work to Social Security Administration.
NOTE: If letter is sent to wife, change to read “. . . until your husband sends in the
Form . . . ”
|
608.
|
AUXILIARY BENEFICIARY SUSPENDED BECAUSE “A” WORKED
R
It has been necessary to suspend benefit payments to your 1 since you are working and expect your earnings for the taxable year to be more than
$2.
Fill
ins:
-
1.
Wife/child/children/family/husband
-
NOTE: Fill-in information must be supplied when the rider paragraph is to be typed onto
the notice being prepared. If a preprinted rider is being requested as an addition
to a letter, no fill-ins are required because all preprinted riders contain complete
paragraph information.
|
609.
|
WORK DEDUCTION FOR THE MONTH IMMEDIATELY PRECEDING THE CURRENT MONTH
If you have returned the benefit payment for 1, the amount deducted will be returned to you.
Fill
in:
-
|
624.
|
WAIVER OF DEDUCTION OVERPAYMENT-AUXILIARY BENEFICIARIES
We have determined that no deductions will be made for the benefits you received for
1.
Fill
in:
-
|
633.
|
OVERPAYMENT — CREDIT MONTHS INVOLVED
Our records show that we paid you $1 too much in 2. In an earlier notice, we told you we held back your benefits for 3 to recover 4 amount. But you recently reported to us that you worked during 5. Because of this work, we cannot credit your benefits for 6 toward the amount you owe for 7. Therefore, the amount shown above that you owe is the $8 that you were overpaid in 9.
Fill
ins:
-
-
-
-
-
-
-
-
-
|
635(A).
|
PENALTY DETERMINATION — GOOD CAUSE NOT FOUND — CURRENT PAYMENT STATUS — EXPLANATION
OF LATE FILING NOT FURNISHED
R
The additional deduction of $1 is being made because you did not submit any evidence or explanation to establish
good cause for the late filing of your report.
If you believe that this determination is not correct, you may request that your claim
be reexamined. If you want this reconsideration, you must request it not later than
60 days from the date you receive this notice. You may make the request through any
Social Security office. If additional evidence is available, you should submit it
with your request.
Fill
in:
-
|
635(B).
|
PENALTY DETERMINATION — GOOD CAUSE NOT FOUND — CURRENT PAYMENT STATUS — EXPLANATION
OF LATE FILING FURNISHED
R
The additional deduction of $1 is required. We considered your reason for late filing but could not establish good
cause based on the information you gave us. Generally, good cause will be found only
when the late filing results from inconvenient or unfavorable circumstances, confusion
regarding Social Security legislation or amendments to the Social Security Act, or
misleading information from an official source.
If you believe that this determination is not correct, you may request that your claim
be reexamined. If you want this reconsideration, you must request it not later than
60 days from the date you receive this notice. You may make your request through any
Social Security office. If additional evidence is available, you should submit it
with your request.
Fill
in:
-
1.
Amount (penalty deduction)
|
636(A).
|
PENALTY DETERMINATION — GOOD CAUSE NOT FOUND — CONDITIONAL BENEFIT STATUS — EXPLANATION
OF LATE FILING NOT FURNISHED
R
The additional deduction of $1 will be made when you are again receiving benefits because you did not submit any
evidence or explanation to establish that you had good cause for the late filing of
your report.
If you believe that this determination is not correct, you may request that your claim
be reexamined. If you want this reconsideration, you must request it not later than
60 days from the date you receive this notice. You may make your request through any
Social Security office. If additional evidence is available, you should submit it
with your request.
Fill
in:
-
1.
Amount (penalty deduction)
|
636(B).
|
PENALTY DETERMINATION — GOOD CAUSE NOT FOUND — CONDITIONAL BENEFIT STATUS — EXPLANATION OF LATE FILING FURNISHED
R
The additional deduction of 1 will be made when you are again receiving benefits. We considered your explanation
for late filing but could not establish good cause based on the reason you gave us.
Generally, good cause will be found only when the late filing results from inconvenient
or unfavorable circumstances, confusion regarding Social Security legislation, or
amendments to the Social Security Act, or misleading information from an official
source.
If you believe that this determination is not correct, you may request that your claim
be reexamined. If you want this reconsideration, you must request it not later than
60 days from the date you received this notice. You may make your request through
any Social Security office. If additional evidence is available, you should submit
it with your request.
Fill
in:
-
1.
Amount (penalty deduction)
|
651.
|
OVERPAYMENT — 30-DAY ADJUSTMENT PARAGRAPH
R
If refund of the amount overpaid is not received within 30 days, an equal amount will
be withheld from the benefits you are receiving. If you do not agree with this determination,
you may request a reconsideration. If you wish a reconsideration, you must request
it not later than 60 days from the date you receive this notice. You should make your
request through any Social Security office. If additional evidence is available, you
should submit it with your request.
|
652.
|
STUDENT ENTITLED — FAMILY MAXIMUM CASE — NO ADJUSTMENT REQUIRED
Due to the entitlement of the student beneficiary, each benefit rate must be reduced
to $1 beginning with the month the student became entitled. Since the correct amount of
benefits was paid to the family effective that month, no adjustment is necessary.
Fill
in:
-
|
656(A).
|
LATE FILING OF REPORT — BENEFICIARY NOT PREVIOUSLY NOTIFIED OF GOOD CAUSE AND PENALTY
— NO CHILD IN-CARE DEDUCTIONS
R
Under the law, an additional amount must be withheld when certain events that affect
a person's benefits are not reported within a specified time. You should have reported
that you did not have a child in your care before you received the benefit payments
for the second month following the month in which you no longer had a child in your
care. Since you did not file the report within this period, we must withhold an additional
$1 from your benefits unless you can establish good cause for late filing. If you believe
you had good cause for not filing before 2, please let us know within 30 days. We will then notify you whether your explanation
establishes good cause. If so, no additional withholding will be required. If you
offer no explanation for late filing, however, we will assume you do not have good
cause and will withhold the additional amount. If withholding is necessary, we will
notify you and then begin recovery of the amount from any benefits payable. However,
if you wish, you may request that the withholding be done over a period of several
months rather than having us withhold all of your benefits until the amount is recovered.
You should contact any Social Security office within 30 days to make this request.
Fill
ins:
-
1.
Amount (penalty deduction)
-
2.
MM/DD/YY (due date for filing an annual report)
|
660.
|
LATE FILING OF REPORT — BENEFICIARY NOT PREVIOUSLY NOTIFIED OF GOOD CAUSE AND PENALTY
— FOREIGN WORK DEDUCTION
R
Under the law, an additional amount must be withheld when certain events that affect
a person's benefits are not reported within a specified time. You should have reported
that you had worked outside the United States before you received the benefit payment
for the second month following the month in which you worked. Since you did not file
the report within this period, we must withhold an additional $1 from your benefits unless you can establish good cause for the late filing.
If you believe you had good cause for not filing before 2, please let us know within 30 days. We will then notify you whether your explanation
establishes good cause. If so, no additional withholding will be required. If you
offer no explanation for late filing, however, we will assume you do not have good
cause and will withhold the additional amount.
If withholding is necessary, we will notify you and then begin recovery of the amount
from any benefits payable. However, if you wish, you may request that the withholding
be done over a period of several months rather than having us withhold all of your
benefits until the amount is recovered. You should write us within 30 days to make
this request.
Fill
ins:
-
1.
Amount (penalty deduction)
-
2.
MM/DD/YY (due date for filing an annual report)
|
662.
|
AUXILIARY BENEFICIARY LIVING WITH W/E ALSO OVERPAID — REQUEST FOR REFUND (to be added
to W/E's notice)
Based on the above, 1, 2, received $3 more than should have been paid. Refund of this amount should also be made as indicated
above.
Fill
ins:
-
1.
Your wife/your husband/your child/your children
-
-
|
663.
|
AUXILIARY BENEFICIARY LIVING WITH W/E ALSO OVERPAID — ADJUSTMENT POSSIBLE (to be added
to W/E's notice)
Based on the above, 1,2, received $2 more than should have been paid. Therefore, it will be necessary to withhold this
amount from payments due. 3 next payment will be for $4 which covers payment through 5. This payment will be sent shortly after 6 3rd.
Fill
ins:
-
1.
Your wife/your husband/your child/your children
-
-
-
-
-
-
|
671.
|
SPOUSE (B1), AGE 62 WHEN LAST CHILD TERMINATED
Since you are now age 62, you will be entitled to actuarially reduced spouse's benefits
immediately if you so elect. Contact any Social Security office if you wish to file
a Certificate of Election.
|
676.
|
COMBINED CHECK — CHECK FOR MONTH SUBSEQUENT TO MONTH OF DEATH ADJUSTED AGAINST CURRENT
BENEFITS
Since the combined payment(s) issued to you and your spouse for 1,2 not been returned, this amount will be deducted in figuring your next payment. This
is in accordance with our previous notice.
Fill
ins:
-
-
|
679.
|
COMBINED CHECK — PRIMARY OR AUXILIARY BENEFICIARY DIES-CHECK FOR MONTH SUBSEQUENT
TO MONTH OF DEATH OUTSTANDING
R
The combined check issued to you and your spouse for any month after the month of
death should not be cashed. The check should be returned to the Treasury Department,
Division of Disbursement, located in the city shown on the face of the check. If it
is not returned within 60 days, an equal amount will be withheld from benefits payable
to you. If you have already returned the check, no further action is necessary on
your part.
|
683.
|
TO WORKING BENEFICIARY — TEMPORARY DEDUCTIONS — DEFERRED RESUMPTION BASED ON AGE 72
No benefits are payable for 1 because you expect to earn 2. Beginning with the month you are 72 years old, you can receive monthly payments
regardless of how much you earn.
If you stop working for wages of more than $3 monthly as an employee or if you stop performing substantial services as a self-employed
person before that time, please notify any Social Security office.
If necessary, final adjustments will be made in your benefit payments when we receive
your annual report of earnings.
Fill
ins:
-
-
2.
Amount or “more than current yearly limit”
-
|
684.
|
COMPLETION OF FORM SSA-21 (OR SSA-22-F4) BY BENEFICIARY (OR PAYEE) WHO HAS MOVED TO
FOREIGN COUNTRY
R
You should complete the enclosed form and return it to us immediately in the enclosed
envelope which requires postage. If we do not receive the completed form within 6
months, benefit payments will be stopped until it is received.
Enclosures: Form SSA-21 and Envelope
NOTE: If Form SSA-22 is used, change the form number under “Enclosures."
|
685.
|
CHECK TO DECEASED BENEFICIARY OUTSTANDING — AMOUNT WITHHELD FROM LUMP-SUM AND/OR UNDERPAYMENT
AWARD (Modify Where More Than One Check)
R
Notice of the death of 1 was not received in time to prevent the mailing of the check for 2. Since this check is still outstanding, we have requested a Social Security office
to immediately look into this matter.
Although you are entitled to $3, the outstanding amount of $ 4 is being withheld from your payment. In this way a check for $5 can be sent you now. If it is later determined that you are due the amount withheld
or the outstanding check is returned, you will be advised.
Fill
ins:
-
-
-
-
4.
Amount of outstanding check(s)
-
|
686.
|
“A” RECEIVING “B” OR “B1” BENEFIT IN COMBINED CHECK — “B” OR “B1” BENEFITS SUSPENDED
BECAUSE SPOUSE IS WORKING
No further benefits as a 1 may be paid to you at this time because of your spouse's earnings.
Fill
in:
-
|
687.
|
LUMP-SUM PAYMENT WIDOW — LUMP-SUM DEATH PAYMENT BEING MADE AS A PMA CHECK WHILE THE
INITIAL “D” AWARD WILL BE MADE AS A CMA PAYMENT
A check for $1 which represents the lump-sum death payment will be sent to you in a few days.
Fill
in:
-
|
691.
|
COMBINED “AB” CHECK FOR MONTH OF DEATH NEGOTIATED BY SURVIVING SPOUSE UNDER “SUPERENDORSEMENT”
PROCESS
Since the combined payment issued to you and your spouse for the month of death was
cashed by you, the necessary adjustment will be made in your next payment.
|
703.
|
SUSPENSION OF BENEFITS OR PAYMENT DEFERRED BEYOND CURRENT YEAR — COMBINED PAYMENTS
— A AND B BENEFICIARIES ENROLLED UNDER SMI (A WORKED)
R
As your benefits are being withheld, you will each be billed for the medical insurance
premiums. Premiums are payable in advance and your first notices will request all
premiums currently due. Thereafter, the notice will request the payment of 3 months'
premiums at a time and will be sent to you shortly before the payments are due. Your
notices will show the months for which you are to pay and the amount each of you is
to pay.
|
704.
|
DEFERRED PAYMENT ACTION-TO RECOVER OVERPAYMENT LIABLE FOR PREMIUMS
A part of your Social Security payment that is being withheld to recover amounts that
you were incorrectly paid is being used to pay your medical insurance premiums.
|
705.
|
DEFERRED PAYMENT ACTION — TO RECOVER OVERPAYMENT REDEFERRED FOR PREMIUMS DUE
This supersedes our previous notice to you. The payment amount and month of payment
have been changed to adjust for medical insurance premiums due or paid in advance.
Thereafter, 1 month's premium will be deducted from your regular monthly benefits.
|
707.
|
ONE-CHECK-ONLY FOLLOWED BY A SUSPENSION — COMBINED CHECK SITUATION (A WORKED) — BOTH
“A” AND “B” ENROLLED IN SMI
The medical insurance premiums must be deducted from benefits when possible. Thus,
in determining the amount of the payment you are to receive, all premiums due through
the month of 1, have been deducted. You will be billed separately for future months. The premiums
are payable in advance and your first billing notices will request all premiums currently
due. Thereafter, the notices will request the payment of 3 months' premiums at a time
and will be sent to you shortly before the payment is due. Your notices will show
the months for which you are to pay and the amount each of you is to pay.
Fill
in:
-
|
708.
|
ONE-CHECK-ONLY FOLLOWED BY A DEFERRED PAYMENT ACTION IN CURRENT YEAR
The medical insurance premiums must be deducted from benefits when possible. Thus,
in determining the amount of the first payment you will receive, all premiums due
through the month of 1 have been deducted. The next payment will be adjusted for all premiums due or paid
in advance. Thereafter, the premium amount will be deducted from your monthly benefit
payment.
Fill
in:
-
|
709.
|
TO SECONDARY BENEFICIARY — MONTHLY BENEFIT PAYABLE LESS THAN $1
The medical insurance premiums of $1 per month are deducted from benefits when possible. After making this deduction the
monthly benefit due you is $2. Therefore, we will withhold your monthly payment and send you $3 at the end of this year covering payment for all months 4 through 5.
Fill
ins:
-
-
-
-
-
|
710.
|
TO SECONDARY BENEFICIARY — MONTHLY BENEFIT PAYABLE IS SAME AS PREMIUM
The medical insurance premiums of $1 per month are deducted from benefits when possible. Since your monthly benefit amount
is exactly $2, we will withhold your monthly benefit payments.
Fill
ins:
-
-
(1)
(2)
|
711.
|
TO SECONDARY BENEFICIARY — MONTHLY BENEFIT PAYABLE IS LESS THAN PREMIUM
The medical insurance premiums of $1 per month are deducted from benefits where possible. However, since your benefits
are less than $2 we will withhold them and bill you for the difference of $3 per month. Your bill will be received a few days before the payment is due and will
be for $4 covering all months 5 through 6.
Fill
ins:
-
-
-
-
-
-
|
716.
|
REPRESENTATIVE PAYEE FOR HI AND/OR SMI ENROLLEE
1 is entitled to 2 effective 3. If you have not yet received a health insurance card for the claimant and Medicare
services are needed, this notice may be used to show eligibility for this insurance.
Fill
ins:
-
-
2.
Hospital insurance/medical insurance/hospital and medical insurance
-
3.
MM/YY or MM/YY and MM/YY respectively
|
718.
|
TERMINATION OF MONTHLY BENEFITS AND HI WITH SMI ENTITLEMENT TRANSFERRED TO NEW ACCOUNT
Your hospital insurance coverage under Medicare has been stopped because you are no
longer entitled to benefits on this record. A representative from the Social Security
office will be in touch with you shortly to help you apply for this coverage on your
own record. Your medical insurance is automatically transferred to your own record
and you will soon receive a new health insurance card showing your own Social Security
number. Please turn in your old health insurance card to any Social Security representative.
|
719.
|
EXPLANATION OF MEDICARE PREMIUMS AND DEDUCTIONS UNDER PUBLIC LAW (P.L.) 97-248, SECTION
278
Section 278 of P.L. 97-248 was enacted in recognition of the fact that a significant
number of Federal employees and retirees qualify for Medicare coverage either on the
basis of their own employment outside the Federal government or on that of their spouse.
However, such employees generally do so on the basis of fewer quarters of coverage
than other beneficiaries. Consequently, Congress acted on the belief that Federal
employees (and the Federal government, as their employer) should bear a more equitable
share of the cost of financing the health benefits to which many of them eventually
become entitled.
The fact that some Federal workers already qualify for Medical does not disadvantage
them with respect to non-Federal workers. Such workers do not stop paying FICA taxes
once they become eligible for Social Security benefits and/or Medicare, but continue
to pay such taxes until they stop working.
The 1.3 percent tax (which is part of the FICA tax) supports the Medicare hospital
insurance trust fund which provides free hospital insurance coverage to beneficiaries
such as yourself. The premium you pay is for medical insurance which does not have
a tax-supported base. Therefore, you are not paying double for you Medicare coverage.
|
721.
|
TO WORKING BENEFICIARY — YEARLY EARNINGS ASSUMED
R
Your benefits have been stopped because you told us you are now working. Since you
gave no estimate of your earnings for this year, we are assuming that you will earn
more than $1. Please notify us if you will not earn over the exempt amount this year. Under the
retirement test provisions, no benefits are withheld unless your yearly earnings are
more than $2.
Fill
ins:
-
-
|
722.
|
TO WORKING BENEFICIARY — WORK MONTH ASSUMED
R
Your benefits have been stopped because you told us that your earnings for this year
will be more than $1. We assume that you are now earning over the monthly exempt amount of $2 or that you are active in self-employment. If not, please let us know. Under the
retirement test provisions, your benefits are payable for any month that you neither
earn over the monthly exempt amount nor are active in self-employment, even though
you earn more than $3.
Fill
ins:
-
-
-
|
728.
|
DISCONTINUANCE OF STATE-BUY-IN DUE TO NON-PAYMENT OF SSI
Because your Supplemental Security Income payments have been stopped, the State will
no longer pay your medical insurance premiums.
(To be used for “buy-in” States in conjunction with paragraph 725, when applicable.)
|
729.
|
CONTINUANCE OF STATE BUY-IN WHEN SSI PAYMENTS STOPPED
Although your Supplemental Security Income payments have been stopped, your medical
insurance premiums will continue to be paid by the State.
(To be used for MAA “buy-in” States in conjunction with paragraph 725, when applicable.)
|
731.
|
SSA-1560-U4 RETURN ADDRESS PARAGRAPH, SEPSC
Return original and last copy of completed form SSA-1560-U4 to:
Social Security Administration
Southeastern Program Service Center
Box 10926
Birmingham, Alabama 35202
|
733.
|
ADDITIONAL INFORMATION REGARDING THE STUDENT'S BENEFITS
R
Student benefits have been stopped because we did not receive the school attendance
report which was previously requested. Within a few days you will receive another
reporting card. If you are still in full-time attendance, you should complete and
return the card to us immediately in the envelope enclosed with the card. If you are
not now attending school full-time but intend to resume attendance in the next few
months, you should contact any Social Security office as soon as possible.
If you visit the office, please take this notice with you.
|
741.
|
DIB TERMINATES-HI/SMI COVERAGE TERMINATES — NO REFUNDS ON REMITTANCES DUE
Since you are no longer entitled to disability benefits, your hospital and medical
insurance coverage under Medicare ends the last day of 1. Please destroy your health insurance card after the last day of coverage indicated
above.
Fill
in:
-
1.
MM/YY (last month Medicare coverage ends)
|
742.
|
DIB TERMINATES — HI/SMI COVERAGE TERMINATES — PREMIUM ARREARAGE EXISTS — NO DIB OVERPAYMENT
OR UNDERPAYMENT
Your medical insurance premiums have only been paid through 1. Therefore, you should send $2 to pay premiums due through 3. Please make your check or money order payable to Health Care Financial Administration
Medicare Insurance, Claim No. 4,” and send it to us in the enclosed envelope.
Enclosure: Envelope
Fill
ins:
-
1.
MM/YY (last month medical insurance premium paid)
-
-
3.
MM/YY (last month medical insurance premiums due)
-
4.
Claim number (include BIC)
|
743.
|
DIB TERMINATES FROM SUSPENSE — DIB UNDERPAYMENT HI-SMI PREMIUMS FOR MONTH FOLLOWING
MONTH OF NOTICE TO BE DEDUCTED FROM DIB UNDERPAYMENT — BENEFICIARY NOT BILLED FOR
SMI PREMIUMS (To be used in conjunction with paragraph No. 741.)
Since you were last paid for the month of 1, you are due benefits for 2. However, your medical insurance premiums were not deducted from your benefits after
that month. You may expect to receive a payment in the amount of $3 from the Treasury Department within a few days. This payment will represent all payments
due you less the medical insurance premiums not previously deducted.
Fill
ins:
-
1.
MM/YY (last month benefits paid)
-
2.
MM/YY (last month benefits due)
-
|
743(A).
|
DIB TERMINATES FROM SUSPENSE — DIB UNDERPAYMENT FOR MULTIPLE MONTHS — HI/SMI PREMIUMS
FOR MONTH FOLLOWING MONTH OF NOTICE TO BE DEDUCTED FROM DIB UNDERPAYMENT — BENEFICIARY
NOT BILLED FOR SMI PREMIUMS
Since you were last paid for the month of 1 you are due benefits for 2 through 3. However, your medical insurance premiums were not deducted from your benefits after
that month. You may expect to receive a check in the amount of $4 from the Treasury Department within a few days. This check will represent all payments
due you less the medical insurance premiums not previously deducted.
Fill
ins:
-
1.
MM/YY (last month benefits paid)
-
2.
MM/YY (last month benefits due)
-
3.
MM/YY (last month benefit payment due)
-
|
744.
|
DIB TERMINATES FROM SUSPENSE — NO DIB OVERPAYMENTS OR UNDERPAYMENTS BENEFICIARY BILLED
FOR SMI PREMIUMS — PREMIUMS ARREARAGE EXISTS (To be used in conjunction with paragraph
No. 741.)
According to our records, your medical insurance premiums have only been paid through
1. Therefore, you should send us $2 to pay premiums due through 3. Please make your check or money order payable to “Health Care Financing Administration
Medicare Insurance, Claim No. 4,” and send it to us in the enclosed envelope. If you have already sent this payment,
please disregard this request.
Enclosure: Envelope
Fill
ins:
-
1.
MM/YY (last month medical insurance premiums paid)
-
-
3.
MM/YY (last month medical insurance due)
-
4.
Claim number (include BIC)
|
745.
|
DIB TERMINATES FROM SUSPENSE-DIB UNDERPAYMENT-BENEFICIARY BILLED FOR SMI PREMIUM —
PREMIUMS ARREARAGE EXISTS WHICH WILL BE DEDUCTED FROM THE NEXT CHECK (To be used in
conjunction with paragraph No. 741.)
Since you were last paid for the month of 1, you are due benefits for 2. However, our records show that your medical insurance premiums have only been paid
through 3. You may expect to receive a payment for $4 from the Treasury Department within a few days. This payment will represent all payments
due you less any unpaid medical insurance premiums. If you have already paid these
premiums, that amount will be refunded.
Fill
ins:
-
1.
MM/YY (last month benefits paid)
-
2.
MM/YY (last month benefits due)
-
3.
MM/YY (last month medical insurance premiums paid)
-
|
745(A).
|
DIB TERMINATES FROM SUSPENSE — DIB UNDERPAYMENT FOR MULTIPLE MONTHS-BENEFICIARY BILLED
FOR SMI PREMIUMS — PREMIUM ARREARAGE EXISTS WHICH WILL BE DEDUCTED FROM THE NEXT CHECK
Since you were last paid for the month of 1, you are due benefits for 2 through 3. However, our records show that your medical insurance premiums have only been paid
through 4. You may expect to receive a check for $5 from the Treasury Department within a few days. This check will represent all payments
due you less any unpaid medical insurance premiums. If you have already paid these
premiums, that amount will be refunded.
Fill
ins:
-
1.
MM/YY (last month benefits paid)
-
2.
MM/YY (first month benefit payment due)
-
3.
MM/YY (last month benefit payment due)
-
4.
MM/YY (last month medical insurance premiums paid)
-
|
746.
|
DIB TERMINATES — HI COVERAGE TERMINATES — NO SMI COVERAGE
Since you are no longer entitled to disability benefits, your hospital insurance coverage
under Medicare ends the last day of 1. Please destroy your health insurance card after the last day of coverage indicated
above.
Fill
in:
-
1.
MM/YY (last month of hospital insurance coverage)
|
747.
|
SMI REFUND PARAGRAPH (To be used in conjunction with paragraph No. 741 when excess
premiums will be refunded by SOBER.)
Medical insurance premiums are paid a month in advance. Therefore, any premiums deducted
from your final payment apply to a noncoverage month and will be refunded to you.
|
748.
|
MEDICARE INELIGIBILITY PARAGRAPH (To be used when beneficiary's DOST and DOCA are
prior to the date of entitlement to HI/SMI. It is also to be used when a Future Cessation
Data (FCD) equal to or earlier than the date of entitlement to HI/SMI is being established.)
Since you are no longer entitled to disability benefits, you are not eligible for
Medicare coverage. Please disregard any previous information you have received or
may receive concerning Medicare coverage.
|
749.
|
DIB TERMINATES-HI/SMI COVERAGE TERMINATES-PREMIUM ARREARAGE EXISTS ALONG WITH DIB
OVERPAYMENT
You should refund the amount shown above within 30 days from the day you get this
letter. If you cannot refund the full amount now, you should send a partial payment.
You should tell us why you cannot pay the full amount and let us know when you will
pay the balance. If you must pay by installments, you should tell us how much you
will pay each month and the date you will make each payment. In addition, your medical
insurance premiums have not been paid for 1. Therefore, you should also include $2 to pay for premiums due. Please make your check or money order payable to “Social
Security Administration, Claim No. 3,” and send it to us in the enclosed envelope.
Enclosure: Refund Envelope
Fill
ins:
-
1.
MM/YY (month(s) medical insurance premiums not paid)
-
-
3.
Claim number (include BIC)
|
749(A)
|
DIB TERMINATES — HI/SMI COVERAGE TERMINATES — PREMIUM ARREARAGE EXISTS FOR ONE MONTH
ALONG WITH DIB OVERPAYMENT
You should refund the amount shown above within 30 days from the day you get this
letter. In addition, you should also include $1 to pay your medical insurance premiums due for 2. Please make your check or money order payable to Social Security Administration,
Claim No. 3 and send it to us in the enclosed envelope.
Enclosure: Envelope
Fill
ins:
-
-
2.
MM/YY (last month medical insurance premium due)
-
3.
Claim number (include BIC)
|
749(B).
|
DIB TERMINATES — HI/SMI COVERAGE TERMINATES — PREMIUM ARREARAGE EXISTS FOR PRIOR MONTHS
ALONG WITH DIB OVERPAYMENTS
You should refund the amount shown above within 30 days from the day you get this
letter. In addition, you should also include $1 to pay your medical insurance premiums due for 2 through 3. Please make your check or money order payable to “Social Security Administration,
Claim No. 4,” and send it to us in the enclosed envelope.
Enclosure: Envelope
Fill
ins:
-
-
2.
MM/YY (first month medical insurance premium due)
-
3.
MM/YY (last month medical insurance premium due)
-
4.
Claim number (include BIC)
|
750.
|
DIB TERMINATED FROM SUSPENSE — DIB OVERPAYMENT EXISTS — BENEFICIARY BILLED FOR SMI
PREMIUMS — PREMIUM ARREARAGE EXISTS (To be used in conjunction with paragraph No.
741.)
You should refund the amount shown above within 30 days from the receipt of this letter.
If you cannot refund the full amount now, you should send a partial payment. You should
tell us why you cannot pay the full amount and let us know when you will pay the balance.
If you must pay by installments, you should tell us how much you will pay each month
and the date you will make each payment. In addition, our records show that your medical
insurance premiums have not been paid for 1. Therefore, you should also include $2 to pay for premiums due. Please make your check or money order payable to “Social
Security Administration, Claim No. 3, ” and send it to us in the enclosed envelope. If you already paid the medical insurance
premiums, you need only refund the incorrect disability payments.
Enclosure: Refund envelope
Fill
ins:
-
1.
MM/YY (last month medical insurance premium due)
-
-
3.
Claim number (include BIC)
|
751.
|
DIB TERMINATED — EXCESS SMI PREMIUMS USED TO REDUCE OVERPAYMENT
Your medical insurance premiums have been paid through 1, although they were only due through 2. We have deducted the premiums for your noncoverage months from the amount of the
overpayment shown above. Therefore, you should refund $3 within 30 days from the day you get this letter. Please make your check or money
order payable to “Social Security Administration, Claim No. 4,” and send it to us in the enclosed envelope.
Enclosure: Envelope
Fill
ins:
-
1.
MM/YY (last month medical insurance premiums paid)
-
2.
MM/YY (last month medical insurance premiums due)
-
-
4.
Claim number (include BIC)
|
752.
|
DIB TERMINATED FROM SUSPENSE — DIB UNDERPAYMENT FOR ONE MONTH — EXCESS PREMIUMS TO
BE REFUNDED BY SOBER
Since you were last paid for the month of 1, you are due benefits for 2. You may expect to receive a check for $3 from the Treasury Department within a few days. In addition, your medical insurance
premiums have been paid through 4, although they were only due through 5. A check in the amount of $6 which represents a refund of medical insurance premiums paid for noncoverage months
will be sent to you shortly.
Fill
ins:
-
1.
MM/YY (last month benefit paid)
-
2.
MM/YY (last month benefit due)
-
-
4.
MM/YY (last month medical insurance premium paid)
-
5.
MM/YY (last month medical insurance premiums due)
-
|
752(A).
|
DIB TERMINATED FROM SUSPENSE — DIB UNDERPAYMENT FOR MULTIPLE MONTHS — EXCESS PREMIUMS
TO BE REFUNDED BY SOBER
Since you were last paid for the month of 1, you are due benefits for 2 through 3. You may expect to receive a check for $4 from the Treasury Department within a few days. In addition, your medical insurance
premiums have been paid through 5, although they were only due through 6. A check in the amount of $7 which represents a refund of medical insurance premiums paid for noncoverage months
will be sent to you shortly.
Fill
ins:
-
1.
MM/YY (last month benefit paid)
-
2.
MM/YY (first month benefit due)
-
3.
MM/YY (last month benefit due)
-
-
5.
MM/YY (last month medical insurance premium paid)
-
6.
MM/YY (last month medical insurance premium due)
-
|
778.
|
REMINDED TO FILE AN ANNUAL REPORT
R
If you earn over $1 in a year, you must file an annual report of earnings for the year. Your earnings
for the entire year must be counted, even if your benefits ended during the year.
Fill
in:
-
|
790.
|
HI AND SMI COVERAGE FOR RD BENEFICIARIES (DIALYSIS)
Your Medicare coverage is based on a kidney condition for which you are receiving
a course of dialysis. If you have participated in self-dialysis training, the 3-month
waiting period for entitlement has been waived. The law provides that Medicare coverage
will end with either the last day of the 12th month after the month a course of dialysis
is discontinued or the 36th month after the month a kidney transplant is received.
If your course of dialysis is discontinued or if you receive a kidney transplant,
please get in touch with any Social Security office.
Please read the enclosed leaflet for a full explanation of your right to question
the determination made on your claim.
Enclosure: SSA-10058
|
791.
|
CLOSED PERIOD — ENTITLEMENT/TERMINATION (DIALYSIS)
Your Medicare coverage begins 1 and is based on a kidney condition for which you have received a course of dialysis.
If you have participated in self-dialysis training, the 3 month waiting period for
entitlement has been waived. The law provides that Medicare coverage will end with
the last day of the 12th month after the month a course of dialysis is discontinued.
Since your course of dialysis was discontinued in 2, your Medicare coverage ends with the last day of 3.
Please read the enclosed leaflet for a full explanation of your right to question
the determination made on your claim. If you again begin a course of dialysis or if
you receive a kidney transplant, please get in touch with any Social Security office
about filing a new claim for Medicare coverage.
Enclosure: SSA-10058
Fill
ins:
-
-
-
|
792.
|
HI/SMI TERMINATION DUE TO RD CESSATION (DIALYSIS)
The law provides that Medicare coverage will end with the last day of the 12th month
after the month a course of dialysis is discontinued. Since your course of dialysis
was discontinued in 1, your Medicare coverage ends with the last day of 2.
Please read the enclosed leaflet for a full explanation of your right to question
the determination made on your claim. If you again begin a course of dialysis or if
you receive a kidney transplant, please get in touch with any Social Security office
about filing a new claim for Medicare coverage.
Enclosure: SSA-10058
Fill
ins:
-
1.
MM/YY (1 month prior to the second fill in)
-
2.
MM/YY (1 month prior to DOTH)
|
793.
|
EQUITABLE RELIEF — RD TERMINATION CASES — DOTH IS EARLIER THAN DOTS — BENEFICIARY
NOT NOTIFIED TIMELY (DIALYSIS)
The law provides that Medicare coverage under the kidney disease provisions of the
Social Security Act ends with the last day of the 12th month after the month a course
of dialysis is ended. Since you discontinued dialysis in 1, your Medicare entitlement would ordinarily end the last day of 2. However, the work needed to end your coverage was not done on time. Therefore, your
medical insurance coverage will remain in effect through the last day of 3. Your hospital insurance coverage ended the last day of 4.
Please read the enclosed leaflet for a full explanation of your right to question
the determination made on your claim. If you should again begin a course of dialysis
or you receive a kidney transplant, please get in touch with any Social Security office
about filing a new claim for Medicare coverage.
Enclosure: SSA-10058
Fill
ins:
-
1.
MM/YY (1 year prior to fourth fill-in)
-
2.
MM/YY (1 month prior to DOTH)
-
3.
MM/YY (1 month prior to DOTS)
-
4.
MM/YY (1 month prior to DOTH)
|
794.
|
HI AND SMI COVERAGE FOR RD BENEFICIARIES (TRANSPLANT)
Your Medicare coverage is based on a kidney condition for which you have received
a kidney transplant. The law provides that this coverage will end with the last day
of the 36th month after the month you received the transplant unless you receive another
kidney transplant or begin a course of dialysis. Since you received a kidney transplant
in 1, your Medicare coverage ends with the last day of 2.
Please read the enclosed leaflet for a full explanation of your right to question
the determination made on your claim. If you should receive another kidney transplant
or begin a course of dialysis, please get in touch with any Social Security office
to insure that you have the proper Medicare coverage.
Enclosure: SSA-10058
Fill
ins:
-
-
|
795.
|
HI/SMI TERMINATION DUE TO RD CESSATION (TRANSPLANT)
The law provides that Medicare coverage will end with the last day of the 36th month
after the month a kidney transplant is received. Since you received a kidney transplant
in 1, your Medicare coverage ends with the last day of 2.
Please read the enclosed leaflet for a full explanation of your right to question
the determination made on your claim. If you should begin a course of dialysis, or
receive another kidney transplant, please get in touch with any Social Security office
about filing a new claim for Medicare coverage.
Enclosure: SSA-10058
Fill
ins:
-
-
|
796.
|
EQUITABLE RELIEF — RD TERMINATION CASES — DOTH IS EARLIER THAN DOTS — BENEFICIARY
NOT NOTIFIED TIMELY (TRANSPLANT)
The law provides that Medicare coverage under the kidney disease provisions of the
Social Security Act ends with the last day of the 36th month after the month in which
a kidney transplant is received. Since you received a kidney transplant in 1, your Medicare coverage would ordinarily end the last day of 2. However, the work needed to end your coverage was not done on time. Therefore, your
medical insurance coverage will remain in effect through the last day of 3. Your hospital insurance coverage ended the last day of 4.
Please read the enclosed leaflet for a full explanation of your right to question
the determination made on your claim. If you should begin a course of dialysis, or
receive another kidney transplant, please get in touch with any Social Security office
about filing a new claim for Medicare coverage.
Enclosure: SSA-10058
Fill
ins:
-
1.
MM/YY (3 years prior to fourth fill-in)
-
2.
MM/YY (1 month prior to DOTH)
-
3.
MM/YY (1 month prior to DOTS)
-
4.
MM/YY (1 month prior to DOTH)
|
841
|
REFERENCES TO TITLE II CLAIM – DUAL ENTITLEMENT CASE (TITLE II DISCLAIMER PARAGRAPHS)
This decision refers only to your claim for Supplemental Security Income payments.
You will receive a separate notice if you also filed a claim for Social Security payments.
|
842.
|
REFERENCE TO TITLE XVI CLAIM — DUAL ENTITLEMENT CASE (TITLE XVI DISCLAIMER PARAGRAPHS)
This decision refers only to your claim for benefits under the Social Security Disability
Insurance Program. If you have not already received a decision about your payments
under the Supplemental Security Income Program, you will receive a separate notice
shortly.
|
850.
|
NH — CAPACITY FOR SGA
We have determined that you are not entitled to Medicare coverage because your condition
is not disabling. In deciding this, we considered how much your condition has affected
your ability to work. We studied your records, including the medical evidence and
your statements, 1 and work experience. If your condition gets worse and keeps you from doing substantial
gainful work, write, call or visit any Social Security office about filing another
application.
Fill
in:
-
1.
And considered your age, education, training.
|
851.
|
NH — IMPAIRMENT NOT SEVERE-MEDICAL CONSIDERATION ALONE
We have determined that you are not entitled to Medicare coverage because your condition
is not disabling. In deciding this, we considered the medical records, your statements,
and how your condition affects your ability to work. If your condition gets worse
and keeps you from working, write, call or visit any Social Security office about
filing another application.
|
852.
|
NH — IMPAIRMENT NOT SEVERE MEDICAL CONSIDERATION ALONE (DATE ER LAST MET)
We have determined that your condition was not disabling on any date through 1, when you last had enough work credits for Medicare coverage. In deciding this, we
considered the medical records, your statements, and how your condition affects your
ability to work.
Fill
in:
-
1.
Date disability I/S expired
|
853.
|
NH OR DISABLED CHILD — IMPAIRMENT NOT EXPECTED TO LAST 12 MONTHS
We have determined that you are not entitled to Medicare coverage because your condition
is not expected to remain severe enough for 12 months in a row to keep you from working.
In deciding this, we considered how much your condition has affected your ability
to work. We studied your records, including the medical evidence and your statements.
If your condition does not improve as expected, write, call or visit any Social Security
office about filing another application.
|
854.
|
NH OR DISABLED CHILD — IMPAIRMENT DID NOT LAST 12 MONTHS
We have determined that you are not entitled to Medicare coverage because your condition
was not severe enough for 12 months in a row to keep you from working. In deciding
this, we considered how much your condition has affected your ability to work. We
studied your records, including the medical evidence and your statements. If your
condition gets worse, write, call or visit any Social Security office about filing
another application. (Omit last sentence for a disabled child.)
|
855.
|
DISABLED CHILD — IMPAIRMENT NOT SEVERE — MEDICAL CONSIDERATION ALONE OR CONDITION
DISABLING BUT DID NOT EXIST BEFORE AGE 22 (OVER AGE 22)
We have determined that you are not entitled to Medicare coverage because your condition
was not disabling before age 22. In deciding this, we considered the medical records,
your statements, and how your condition affects your ability to work.
|
856.
|
DISABLED CHILD — IMPAIRMENT NOT SEVERE — MEDICAL CONSIDERATION ALONE OR CONDITION
DISABLING BUT DID NOT EXIST BEFORE AGE 22 (UNDER AGE 22)
We have determined that you are not entitled to Medicare coverage because your condition
is not disabling. In deciding this, we considered the medical evidence and your statements.
|
857.
|
DISABLED CHILD — CAPACITY FOR SGA — VOCATIONAL CONSIDERATION (OVER AGE 22)
We have determined that you are not entitled to Medicare because your condition was
not disabling before age 22. In reaching this decision, we considered how much your
condition has affected your ability to work. We studied your records, including the
medical evidence, and considered your education and training.
|
858.
|
DISABLED CHILD — CAPACITY FOR SGA — VOCATIONAL CONSIDERATION (UNDER AGE 22)
We have determined that you are not entitled to Medicare coverage because your condition
is not disabling. In deciding this, we studied your records, including the medical
evidence, and considered your education and training.
|
859.
|
NH — NOT DISABLED BEFORE INSURED STATUS EXPIRED
We have determined that you are not entitled to Medicare coverage because your condition
was not disabling on any date through 1, when you last had enough work credits for Medicare coverage. In deciding this, we
studied your records, including the medical evidence and you statements 2 and work experience in determining how your condition affected your ability to work.
Fill
ins:
-
1.
Date disability I/S expired
-
2.
And considered your age, education, training.
|
860.
|
NH - NOT INSURED AT ALLEGED ONSET OR LATER
We have determined that you are not entitled to Medicare coverage. The reason you
are not entitled is that you do not meet the earnings requirement of the law at the
time you state you became disabled or at any later date.
It is important for you to know that we have not made any determination as to whether
or not you are disabled within the meaning of the law. Since you do not meet the earnings
requirement, it has not been necessary to decide whether you meet the disability requirement.
The attached explains the earnings requirements for Medicare for the disabled.
|
861.
|
DISABLED WIDOW(ER)'S PRESCRIBED PERIOD EXPIRED BEFORE ALLEGED ONSET
We have determined that you are not entitled to Medicare coverage. To be entitled,
your condition must have been disabling within the meaning of the law on or before
1, the date the specified 7-year period ended for you. Since you state that your condition
first became disabling on 2, which is after the end of the 7-year period, you are not entitled to Medicare coverage.
Fill
ins:
-
-
|
862.
|
NH - EXPLANATION OF DISABILITY REQUIREMENT
To be considered disabled, a person must be unable to perform any substantial gainful
work due to a medical condition which has lasted or can be expected to last for a
continuous period of at least 12 months. The impairment must be so severe as to prevent
the person from working not only in the person's usual occupation but in any other
substantial gainful work considering age, education, training and work experience.
|
863.
|
DISABLED WIDOW(ERS) — EXPLANATION OF THE DISABILITY REQUIREMENT AND THE PRESCRIBED
PERIOD
Widows, widowers, or surviving divorced spouses between ages 50 and 65 may qualify
for Medicare coverage only if they meet the disability requirement of the law within
a specified 7-year period. A widow, widower, or surviving divorced spouse may be considered
disabled only if a physical or mental impairment exists that is so severe as to ordinarily
prevent a person from working. The disability must have lasted or be expected to last
for a continuous period of at least 12 months. The person's disability must start
not later than 7 years after the death of the wife or husband, or for a widow/widower
or surviving divorced spouse, formerly entitled to mother's/father's benefits, not
later than 7 years after those benefits ended; or for a person previously entitled
to disabled widow's or widower's benefits or Medicare coverage based on disability
who became disabled again, not later than 7 years after the prior entitlement ended.
|
864.
|
EXPIRATION OF WIDOW(ER)'S PRESCRIBED PERIOD
The last day of your specified period 1,
2.
Fill
ins:
-
1.
Is (if the P/P ends on a future date)/was (if the P/P ended on a past date)
-
|
865.
|
CHILDHOOD DISABILITY — LAW PARAGRAPH — CLAIMANT AGE 22 OR OVER
A disabled child age 18 or over may be entitled to Medicare coverage at age 20 if
the person has a physical or mental condition severe enough to keep the person from
doing any substantial gainful work. The condition must have begun before age 22 and
lasted, or be expected to last for 12 months in a row.
|
866.
|
CHILDHOOD DISABILITY — LAW PARAGRAPH — CLAIMANT NOT YET AGE 22
A disabled child age 18 or over may be entitled to Medicare coverage at age 20 if
the person has a physical or mental condition severe enough to keep the person from
doing any substantial gainful work. The condition must have begun before age 22 and
lasted, or be expected to last for 12 months in a row. If your condition gets worse
before age 22, and keeps you from doing any substantial gainful work, write, call
or visit any Social Security office about filing another application.
|
867.
|
WIDOW(ERS), MOTHER, FATHER OR SURVIVING DIVORCED SPOUSE ENTITLED TO SURVIVORS BENEFITS
— CLAIM FILED FOR MEDICARE COVERAGE — EXPLANATION OF DISABILITY REQUIREMENT FOR MEDICARE
COVERAGE
A widow, widower, surviving divorced spouse, mother or father entitled to survivors
benefits who has a physical or mental condition that is severe enough to ordinarily
keep a person from working may be entitled to Medicare coverage if she or he meets
certain age requirements. The disability must have lasted or be expected to last for
12 months in a row. The person's disability must not start later than 7 years after
the month of death of the spouse or no later than 7 years after prior entitlement
to Medicare coverage as a disabled widow(er) ended.
|
868.
|
WIDOW(ERS) NOT DISABLED — LACK OF SEVERITY
We have determined that you are not entitled to Medicare coverage because your condition
is not severe enough. In deciding this, we considered the medical evidence and your
statements. Should your condition get worse before your specified 7-year period ends,
write, call or visit your Social Security office about filing another application.
|
869.
|
WIDOW(ERS) — NOT DISABLED AT ANY TIME PRESCRIBED PERIOD REQUIREMENT MET FOR DEEMED
ENTITLEMENT TO MEDICARE COVERAGE
We have determined that you are not entitled to Medicare coverage because your condition
was not disabling on or before 1, the date your specified period of eligibility for benefits ended. In deciding this,
we considered the medical evidence and your statements.
Fill
in:
-
1.
Last day of prescribed period
|
870.
|
NH — DISABLED WIDOW(ERS) OR CHILD — APPLICANT DOES NOT WANT TO CONTINUE DEVELOPMENT
OF CLAIM
Since you did not wish to continue the processing of your claim, we determined based
on the evidence in file, that you are not entitled to Medicare coverage because your
condition is not disabling.
|
872.
|
NH — DISABLED WIDOW(ERS) OR CHILD — FAILURE TO FOLLOW PRESCRIBED TREATMENT
We have determined that you are not entitled to Medicare coverage because you are
not following the treatment prescribed for you. A person who is unable to do any substantial
gainful work may qualify for Medicare coverage, but not if he/she refuses to follow
prescribed treatment that could restore his/her ability to work. If you decide to
follow the prescribed treatment, or if you have more information showing why you should
not, write, call, or visit any Social Security office.
|
874.
|
WIDOW(ERS) NOT DISABLED — IMPAIRMENT IS SEVERE AT TIME OF ADJUDICATION BUT NOT EXPECTED
TO LAST 12 MONTHS
We have determined that your are not entitled to Medicare coverage because your condition
is not expected to remain severe enough for 12 months in a row to keep you from working.
In deciding this, we considered the medical evidence and your statements. If your
condition does not improve as expected, write, call or visit any Social Security office
about filing another application.
|
875.
|
WIDOW NOT DISABLED — IMPAIRMENT NO LONGER SEVERE AT TIME OF ADJUDICATION AND DID NOT
LAST 12 MONTHS
We have determined that you are not entitled to Medicare coverage because your condition
was not severe enough for 12 months in a row to keep you from working. In deciding
this, we considered the medical evidence and your statements. If your condition gets
worse, write, call or visit any Social Security office about filing another application.
|
876.
|
NH — DISABLED WIDOW(ERS) OR CHILD — INSUFFICIENT EVIDENCE FURNISHED
We have determined that you are not entitled to Medicare coverage because the evidence
in your file does not show that your condition is disabling. Under the law, the applicant
is responsible for furnishing evidence to support a Medicare claim. Although you have
been requested to furnish additional evidence, you have not done so.
|
877.
|
NH — DISABLED WIDOW(ERS) OR CHILD FAILS OR REFUSES TO SUBMIT TO MEDICAL EXAMINATION
We have determined that you are not entitled to Medicare coverage because the evidence
we now have does not show that your condition is disabling. We based our determination
on this evidence because you did not take the medical examination we asked you to
have at our expense. The examination was needed to fully evaluate your condition.
|
881.
|
NH OR WIDOW(ER) HAS DEMONSTRATED ABILITY TO ENGAGE IN SGA DESPITE CONDITION
We have determined that you are not entitled to Medicare coverage because the work
you are doing despite your condition shows you are able to do some type of substantial
gainful work. We have not made any determination as to whether or not your medical
condition is severe enough to meet the disability requirement since you are doing
substantial gainful work.
|
883.
|
NH DEMONSTRATED ABILITY TO ENGAGE IN SGA DESPITE IMPAIRMENT WITHIN 29 MONTHS BEFORE
ATTAINING AGE 65
We have determined that you are not entitled to Medicare coverage. A person who has
been disabled for at least 29 full calendar months before reaching age 65 may be eligible
for Medicare coverage based on disability. We find that the work which you did despite
your condition, before you reached 65, showed that you were not disabled. A medical
condition may require reducing one's hours of work or giving up one's regular line
of work; but a person may not be entitled to Medicare coverage unless the disability
prevents substantial gainful work in any job.
|
884.
|
NH — CLAIM FILED AFTER DEATH — NOT DISABLED AT ANY TIME EARNINGS REQUIREMENT MET
1 was not entitled to Medicare coverage because 2 condition was not disabling through 3, when 4 last had enough work credits to qualify for Medicare coverage. In deciding this,
we considered how much 2 condition had affected 2 ability to work. We studied 2 records, including the medical evidence and your statements, and considered 2 age, education, training and work experience.
Fill
ins:
-
-
-
3.
Date disability I/S last met
-
|
885.
|
NH — CLAIM FILED AFTER DEATH — NOT DISABLED — LACK OF SEVERITY
1 was not entitled to Medicare coverage at the time of 2 death because 2 condition was not severe enough to prevent 3 from doing any substantial gainful work, nor was it the cause of 2 death. In deciding this, we considered how much 2 condition has affected 2 ability to work. We studied 2 records, including the medical evidence and your statements, and considered 2 age, education, training and work experience.
Fill
ins:
-
-
-
|
886.
|
NH — CLAIM FILED AFTER DEATH — NOT DISABLED — IMPAIRMENT IS SEVERE AT TIME OF DEATH
BUT WOULD NOT HAVE BEEN EXPECTED TO LAST 12 MONTHS
1 was not entitled to Medicare coverage at the time of 2 death. Although 2 condition was severe at the time of 2 death, it was not expected to last for 12 months in a row, nor was it the cause of
2 death. In deciding this, we considered the medical evidence and statements in file,
and considered 2 age, education, training and work experience.
Fill
ins:
-
-
|
887.
|
NH — CLAIM FILED AFTER DEATH — NOT DISABLED — IMPAIRMENT NO LONGER SEVERE AT TIME
OF DEATH AND DID NOT LAST 12 MONTHS
1 was not entitled to Medicare coverage at the time of 2 death because 2 condition was not severe enough for 12 months in a row to keep 3 from working, nor was it the cause of 2 death. In deciding this, we considered how much 2 condition has affected 2 ability to work.
We studied 2 records, including the medical evidence and statements in file, and considered 2 age, education, training and work experience.
Fill
ins:
-
-
-
|
888.
|
NH — CLAIM FILED AFTER DEATH — INSUFFICIENT EVIDENCE
Under the law, the applicant is responsible for furnishing evidence to support his/her
Medicare claim. Although you have been requested to furnish additional evidence, you
have not done so. Therefore, a determination has been made based on the evidence in
file. This evidence does not show that 1 condition was disabling.
Fill
in:
-
|
889.
|
NH — CLAIM FILED AFTER DEATH — DENIAL — APPLICANT DOES NOT WANT TO CONTINUE DEVELOPMENT
OF CLAIM
1 was not entitled to Medicare coverage. Since you indicated that you did not wish
to continue the processing of 2 claim, a determination has been made based on the evidence in file. This evidencedoes
not show 2 condition was disabling.
Fill
ins:
-
-
|
890.
|
NH — CLAIM FILED AFTER DEATH — DENIAL — IMPAIRMENT WAS SEVERE BUT CLAIMANT FAILED
TO FOLLOW PRESCRIBED TREATMENT
1 was not entitled to Medicare coverage because 2 was not following the treatment prescribed for 3 at the time of 4 death. A person who is unable to do any substantial gainful work may qualify for
Medicare coverage, but not if 2 refuses to follow prescribed treatment that could restore 4 ability to work.
Fill
ins:
-
-
-
-
|
891.
|
NH — CLAIM FILED AFTER DEATH — NOT DISABLED AT ANY TIME EARNINGS REQUIREMENT MET —
MEDICAL CONSIDERATION ALONE
1 was not disable through 2, when 3 last had enough work credits for Medicare coverage. In deciding this, we considered
medical evidence, your statements, and how the condition affected 4 ability to work.
Fill
ins:
-
-
2.
Date disability I/S last met
-
-
|
892.
|
NH — CLAIM FILED AFTER DEATH — NOT DISABLED — LACK OF SEVERITY — MEDICAL CONSIDERATION
ALONE
1 was not entitled to Medicare because 2 condition was not severe enough to prevent any substantial gainful work, nor was
it the cause of 2 death. In deciding this, we considered medical evidence, your statements, and how
the condition affected 2 ability to work.
Fill
ins:
-
-
|
893.
|
DIB OR CBD MEDICAL CESSATION
The law provides that an individual's disability period shall end if the person is
able to do substantial gainful work. The law also provides that an individual's period
of disability will continue for the month disability ends and the following 2 months.
The medical evidence in your case shows that you became able to do substantial gainful
work 1. Accordingly, your period of disability ends the last day of 2.
Fill
ins:
-
-
|
894.
|
DIB OR CDB CESSATION — WORK ACTIVITY (NO TRIAL WORK PERIOD)
The law provides that an individual's disability period shall end if the person becomes
able to do substantial gainful work. The law also provides that an individual's period
of disability will continue for the month disability ends and the following 2 months.
The evidence in your case shows that you became able to do substantial gainful work
in 1. Accordingly, your period of disability ends the last day of 2.
Fill
ins:
-
-
|
895.
|
DIB OR CDB CESSATION — WHEREABOUTS UNKNOWN OR FAILURE TO COOPERATE — REQUIRED INFORMATION
NOT SUBMITTED
Information is needed to determine whether you are still disabled. Although you have
been requested to furnish the required information, it has not been submitted. Therefore,
we have determined that your disability ended in 1. The law provides that an individual's period of disability will continue for the
month disability ends and the following 2 months. Accordingly, your period of disability
ends the last day of 2.
Fill
ins:
-
-
|
896.
|
DIB OR CDB CESSATION — WHEREABOUTS UNKNOWN OR FAILURE TO COOPERATE — REQUESTED MEDICAL
EXAMINATION NOT TAKEN
Information is needed to determine whether you are still disabled. Although you have
been requested to take a medical examination at our expense, you have not complied
with our request. Therefore, we have determined that your disability ended in 1. The law provides that an individual's period of disability will continue for the
month disability ends and the following 2 months. Accordingly, your period of disability
ends the last day of 2.
Fill
ins:
-
-
|
897.
|
DISABILITY ENDS PRIOR TO BEGINNING OF MEDICARE COVERAGE
If your condition again prevents you from doing substantial gainful work before age
65, you may file a new application for Medicare based on disability. If you apply
promptly and are again found disabled, months already accumulated toward your 24-month
waiting period for Medicare coverage could be used to determine when Medicare coverage
will begin in your new period of disability.
|
898.
|
DISABILITY ENDS AFTER MEDICARE COVERAGE BEGINS
If your condition again prevents you from doing substantial gainful work before age
65, contact any Social Security office about filing a new application for Medicare
based on disability. If you act promptly and you are again found disabled, your Medicare
coverage could begin with the first full month in which you were again disabled.
|
899.
|
CDB REENTITLEMENT NOTICE
Although your entitlement to Medicare benefits based on childhood disability ceased,
you may again become entitled to Medicare based on childhood disability if you become
disabled within the 7-year reentitlement period prescribed in the law. The last date
of the specified 7-year period in your case is 1.
If, however, you perform enough work to become insured on your own earnings record
and again become disabled, you can become entitled to disability insurance benefits
even though your second disability did not begin within the prescribed 7-year period.
Fill
in:
-
1.
Enter the last day of the 84th month following the date the child's disability ceased
|
900.
|
MULTIPLE CLAIMS — BENEFITS BEING PAID ON ONE — CURRENT CLAIM BEING DENIED
You will continue to receive benefits as specified in the Social Security Award Certificate
previously sent to you.
|
901.
|
MEDICARE COVERAGE TERMINATION
Medicare coverage for a disabled beneficiary begins with the 25th month of entitlement
to disability benefits. If you are currently entitled or scheduled to become entitled
to Medicare the month after the date of this notice, your coverage under Medicare
ends the last day of 1 since you are no longer entitled to disability benefits. If you are not entitled
to Medicare as described above, you are not entitled to any coverage. This notice
replaces information you may have received concerning Medicare coverage.
Fill
in:
-
1.
The insert date will be the latest of the following:
-
a.
The month following the month the notice is mailed to the beneficiary, or
-
b.
The last month benefits are payable (item 18A of the SSA-833.
|
902.
|
DWB CESSATION — MEDICAL EVIDENCE INDICATES ABILITY TO PERFORM SGA
You have been entitled to Medicare based on disability under a special provision of
the Social Security Act which provides for disabled widows and widowers under age
60. To qualify for such entitlement an individual must have a condition so severe
as to ordinarily prevent her/him from working. Medical conditions which meet this
requirement are described in the Social Security Regulations; disability ends when
this requirement is not met. The law provides, however, that an individual's period
of disability will continue for the month the disability ends and the 2 following
months. The medical evidence in your case shows that your condition does not meet
the disability requirement of the law in 1. Accordingly, your period of disability ends the last day of 2. If your condition worsens, you should contact your Social Security office about
filing a new application.
Fill
ins:
-
-
|
903.
|
MEDICARE TERMINATION — DISABILITY ENDS PRIOR TO MEDICARE COVERAGE
Since your disability has ended, you will not be entitled to coverage under Medicare.
|
904.
|
MEDICARE TERMINATION — DISABILITY ENDS AFTER MEDICARE COVERAGE BEGINS
Since your disability has ended, your Medicare coverage will end the last day of 1. Please destroy your health insurance card after the last day of coverage indicated
above.
Fill
in:
-
|
905.
|
EPE CASE — CESSATION — 9 MONTHS OF TRIAL WORK COMPLETE — BENEFICIARY PERFORMING SGA
A person's disability ends if he or she becomes able to do substantial gainful work.
(At the present time earnings over $1 a month usually will be considered substantial and gainful.) A period of disability
continues for the month disability ends and 2 additional months. Not until a person
has completed a 9-month trial work period is a decision made as to whether he or she
has become able to do substantial gainful work.
The evidence in your case shows that you completed a 9-month trial period in 2 and became able to do substantial gainful work in 3.
Fill ins:
-
-
-
|
906.
|
EPE CASE — EXPLANATION OF 15-MONTH REINSTATEMENT PERIOD
After completion of the 9-month trial work period, the law provides for an additional
15-month period in which individuals can further test their ability to work. If, during
this 15-month period you stop doing substantial gainful work, your status as a disabled
individual may be reinstated.
|
907.
|
EPE CASE — IMPAIRMENT-RELATED WORK EXPENSES NOT ALLOWED AS CLAIMED
Although you reported impairment-related work expenses, we cannot allow them because
they do not meet the definition of impairment-related work expenses.
|
908.
|
EPE CASE — IMPAIRMENT-RELATED WORK EXPENSES INSUFFICIENT TO REDUCE EARNINGS BELOW
SGA
Although you reported impairment-related work expenses which we allowed, they are
not enough to reduce your earnings below the monthly amount generally considered to
be substantial gainful work.
|
909.
|
EPE CASE — 9 MONTHS OF TRAIL WORK COMPLETE — MEDICAL REVIEW — DISABILITY CONTINUES
You previously received a notice that you completed a 9-month trial work period. You
were told of special provisions of the law available to you if you continued to have
a disabling impairment. The medical evidence in your case show that your condition
continues to be disabling within the meaning of the law. Therefore, your status is
unchanged.
You must, however, report promptly any changes which may affect your status. Let us
know if:
-
•
You start working or you are currently working and your work activity stops; or
-
•
You previously reported your work but your duties or pay have changed; or
-
•
Your doctor says your condition has improved; or
-
•
You start to pay for work expenses related to your disability or the amounts you pay
for work expenses related to your disability changes.
This information will be used to decide if you still meet the requirements for continued
eligibility under the special provisions of the Social Security Act.
|
910.
|
EPE CASE — 9 MONTHS OF TRIAL WORK COMPLETE — MEDICAL REVIEW — DISABILITY CEASES
You previously received a notice that you completed a 9-month trial work period. You
were told of special provisions of the law available to you if you continued to have
a disabling impairment. The medical evidence in your case, however, shows that your
condition stopped being disabling within the meaning of the law as of 1. Accordingly, your eligibility for these special provisions ends.
Fill
in:
-
|
911.
|
EPE CASE — MEDICARE HAS BEGUN PRIOR TO END OF TWP
A special provision of the law allows for continuation of Medicare coverage for at
least 39 months after the end of the 9-month trial work period if you continue to
have a disabling impairment. This protection could be extended if you stop doing substantial
gainful work or if your earnings are significantly reduced. If this should happen,
you should contact any Social Security office. You will be notified later when your
Medicare coverage will actually end.
|
912.
|
EPE CASE — IF 24TH MONTH OF ENTITLEMENT HAS NOT BEEN REACHED PRIOR TO END OF TWP
Even though we determined your work to be substantial and gainful, due to a special
provision of the law, if you continue to have a disabling impairment, your Medicare
coverage will begin in 1. The law allows for at least 24 months of coverage if you continue to have a disabling
impairment, and this protection could be extended if you stop doing substantial gainful
work or if your earnings are significantly reduced. If this should happen, you should
contact any Social Security office. You will be notified later about termination of
Medicare coverage.
Fill
in:
-
|
913.
|
EXPIRATION OF DISABILITY INSURED STATUS
Your Social Security record at the time you filed your application shows that you
1 the earnings requirement for Medicare based on disability until 2. Any additional earnings which may be credited to your record after the time you
applied may, of course, extend this date.
Fill
ins:
-
1.
Meet (if I/S expires on a future date)/met (if I/S expired on a past date)
-
2.
Date the disability requirement is last met
|
914.
|
STATE AGENCY AND M.D. PARTICIPATION IN DECISION
The decision on your claim was made by the Social Security Administration on the basis
of a disability determination by an agency of the State in which you live. Physicians
and other trained disability evaluation personnel in the State agency participate
in making such determinations.
|
916.
|
PRIOR FREEZE NOT AFFECTED BY CURRENT DENIAL
A period of disability for Medicare coverage was previously established for you and
later ended. The denial of your current application does not affect any rights from
your previous disability period.
|
917.
|
PERIODIC REVIEW SCHEDULED
Your claim will be reviewed from time-to-time to see if you are still eligible for
Medicare based on disability or blindness. When your claim is reviewed, you will be
contacted if there are any questions.
|
918.
|
LEAD-IN LANGUAGE FOR CLOSED PERIOD AND LATER ONSET DATE ALLOWANCES
We have now completed our consideration of your claim. We previously sent you a notice
that you meet the medical requirements for Medicare coverage. This notice tells you
whether you meet the nonmedical requirements. Together, they explain the determination
made in your claim.
|
919.
|
DISABILITY REQUIREMENT AND 7-YEAR PERIOD ATTACHMENT
An explanation of the disability requirement and the 7-year period is attached.
|
920.
|
DISABILITY AND EARNINGS REQUIREMENT ATTACHMENT
An explanation of the disability requirement and the earnings requirement is attached.
|
940.
|
DUAL ENTITLEMENT — SUBSEQUENT AWARD — MEDICARE AWARDED PREVIOUSLY AND WILL CONTINUE
ON FIRST ACCOUNT
This notice in no way affects your Medicare benefits.
|
941.
|
EXPEDITED APPEALS PROCESS
There is a different way to appeal if you think the Social Security law is not constitutional.
If is called expedited appeal. If you choose expedited appeal, after an agreement
is signed by you and by our representative, you can go directly to court for a decision
about whether the law is constitutional. The Social Security Administration cannot
make that decision. Only the court can decide if the law is constitutional. Social
Security will not make any other appeal decision about your claim for benefits if
you choose an expedited appeal.
If you want to use this appeal or have any questions, you should contact any Social
Security office within 60 days to file a written request.
|
950.
|
LEAD-IN PARAGRAPH FOR AWARD NOTICES
We are writing to let you know that 1 entitled to Social Security benefits.
Fill
in:
-
1.
You are/beneficiary's name is/your children are
|
958.
|
FORMER REPRESENTATIVE PAYEE NOTIFIED STUDENT BENEFITS WILL BE PAID DIRECTLY TO STUDENT
R
Under a recent change, every competent Social Security beneficiary who attains age
18 will be paid directly. Therefore, if you previously received payment on behalf
of the above named-student, any benefits now due will be paid to him.
|
960.
|
DIB/RIB CLAIM, RIB DENIED — NO DECISION ON DIB
You are not entitled to retirement insurance benefits because you are not yet 62.
According to the information we have, your date of birth is 1. This decision concerns only your retirement application. You will be notified as
soon as a decision has been made on your disability application.
Fill
in:
-
1.
Established date of birth
|
961.
|
DIB/RIB CLAIM, RIB DENIED — DIB ALLOWANCE
You are not entitled to retirement insurance benefits because you are not yet 62.
According to the information we have, your date of birth is 1. This decision does not affect the disability benefits to which you are entitled.
Fill
in:
-
1.
Established date of birth
|
970.
|
TITLE II OFFSET CASES WHEN A FEE FOR REPRESENTATION IS INVOLVED (OFFSET ADJUSTMENT
NOTICE)
Approved fees for representation may be subtracted from Social Security benefits used
to decide the amount of 1 income we count for Supplemental Security Income (SSI) purposes. Therefore, if a
fee is approved, we will review 2 claim to decide if we owe 3 money.
The local Social Security office is told whenever fees are approved, but you may be
told sooner. Please contact your local office if you get a letter about approved fees.
This may help us decide sooner if we owe 4 money. If you visit your local office, please bring the letter about the fees with
you.
Fill
ins:
-
-
-
-
NOTE: This paragraph should precede the referral paragraph on the adjustment notice.
|
980.
|
AUTHORIZED CHECK EQUALS AMOUNT OF PAST-DUE BENEFITS WITHHELD
The above fee represents the total amount previously withheld from the claimant's
past-due benefits.
|
980.1.
|
AUTHORIZED CHECK IS LESS THAN AMOUNT OF PAST-DUE BENEFITS WITHHELD
After deduction of the above authorized fee, $1 is payable. A check for this amount is being sent to the claimant (add: “and his
family” if auxiliary involved).
Fill
in:
-
|
980.4.
|
AUTHORIZED OHA FEE EQUALS AMOUNT OF PAST-DUE BENEFITS WITHHELD
A fee in the amount of $1 has been authorized to your attorney by order of the Office of Hearings and Appeals.
A check for this amount will be sent to him shortly. This amount represents the total
amount previously withheld out of your past-due benefits.
A copy of this letter is being sent to your attorney.
Fill
in:
-
|
980.5.
|
AUTHORIZED OHA FEE IS LESS THAN AMOUNT OF BENEFITS WITHHELD
A fee in the amount of $1 has been authorized to your attorney by order of the Office of Hearings and Appeals.
A check for this amount will be sent to him shortly. We previously informed you that
the amount of $2 remains.
A check for the latter amount is being sent to you (add: “and your family” if auxiliary
involved).
A copy of this letter is being sent to your attorney.
Fill
ins:
-
-
|
980.6.
|
AUTHORIZED OHA FEE EXCEEDS AMOUNT OF PAST-DUE BENEFITS WITHHELD
A fee in the amount of $1 has been authorized to your attorney by order of the Office of Hearings and Appeals.
We previously informed you that the amount of $2 was withheld from your past-due benefits. A check for this amount is being sent to
your attorney. The payment of the remaining portion of the authorized amount is a
matter to be arranged with your attorney.
A copy of this letter is being sent to your attorney.
Fill
ins:
-
-
|
981.1.
|
FEE WAIVER OR STATEMENT THAT NO FEE WILL BE CHARGED
Section 206(a) of the Social Security Act requires an attorney to obtain authorization
from the Social Security Administration before he may charge any fee for his services.
This section of the law also provides that up to 25 percent of a claimant's past-due
benefits can be withheld and used toward the payment of such fees. However, since
your attorney has advised the Social Security Administration that he will not charge
a fee for his services before the Administration no part of your past-due benefits
has been withheld for direct payment to the attorney.
|
981.2.
|
WAIVER OF RIGHT TO DIRECT PAYMENT
Section 206(a) of the Social Security Act requires an attorney to obtain authorization
from the Social Security Administration before charging any fee for services. This
section of the law also provides that up to 25 percent of a claimant's past-due benefits
can be withheld and used toward the payment of such fees. However, your attorney has
requested the Social Security Administration to release all past-due benefits to you.
If your attorney desires to charge a fee, a petition for approval of the fee should
immediately be filed with the local Social Security Office. The Social Security Administration
should also be notified if no fee is to be charged.
|
981.3.
|
FUTURE MONTH OF ENTITLEMENT CASE — NO PAST-DUE BENEFITS AVAILABLE
Section 206(a) of the Social Security Act requires an attorney to obtain authorization
from the Social Security Administration before charging any fee for services rendered
the claimant. This section of the law also provides that up to 25 percent of a claimant's
past-due benefits can be used toward the payment of such fees. However, no past-due
benefits are available for direct payment to the attorney since your first month of
entitlement to benefits is after the month of the favorable decision. If the attorney
has not yet done so, a petition for approval of a fee should be filed immediately
even though no benefits are available for direct payment of the fee. If no fee is
to be charged and the representative is waiving his fee, a statement to that effect,
signed and dated by your representative must be forwarded to the administration.
|
982.
|
FEE PETITION INCOMPLETE AFTER FIELD OFFICE CONTACT
Since the information regarding services rendered your client has not been furnished
as required by Social Security Regulation 404.976(a), we have evaluated your services
as evidenced by our records.
|
983.
|
REPRESENTATIVE NOT AN ATTORNEY
Section 206(a) of the Social Security Act requires a representative to obtain authorization
from the Social Security Administration before he may charge any fee for his services.
If the representative has not yet done so, he should immediately file a petition for
approval of a fee. If no fee is to be charged and the representative is waiving his
fee, a statement to that effect, signed and dated by you and your representative must
be forwarded to the Administration.
|
985.
|
FEE WAIVER (OR STATEMENT THAT NO FEE WILL BE CHARGED) RECEIVED AFTER PAST-DUE BENEFITS
HAVE BEEN WITHHELD
Section 206(a) of the Social Security Act requires an attorney to obtain authorization
from the Social Security Administration before he may charge any fee for his services.
This section of the law also provides that up to 25 percent of a claimant's past-due
benefits can be withheld and used toward the payment of such fees. However, since
your attorney has advised the Social Security Administration that he will not charge
a fee for his services before the Administration, benefits withheld in the amount
of $1 will be released to 2 soon.
A copy of this letter is being sent to your attorney.
Fill
ins:
-
-
|
986.
|
PRIOR PAYMENT TO ATTORNEY — ADDITIONAL BENEFITS AVAILABLE
You were previously notified that a fee in the amount of $ 1 had been authorized to your attorney, and a check in the amount of $2 was being sent to 3. Since this amount was less than the authorized amount, we are withholding $4 from the additional past-due benefits payable on this claim to satisfy the unpaid
balance of the authorized fee. If you have already paid the balance of the approved
fee, a statement to that effect signed and dated by you and your attorney will be
sufficient to release the past-due benefits to you.
Fill
ins:
-
-
-
-
4.
Amount of additional withholding
|
987.
|
QUESTIONABLE ATTORNEY CLIENT RELATIONSHIP
Payment of $1 (which represents 25 percent of past-due benefits) has not been included in your
first payment. Your Social Security office will be getting in touch with you soon.
More information is needed as to whether you appointed an attorney to represent you
in pursuing your Social Security claim.
Fill
in:
-
1.
Dollar amount equal to 25 percent of past-due benefits
|
1000.
|
GOVERNMENT PENSION TOTAL OFFSET
The law requires that monthly benefits payable under Social Security to spouses, including
surviving and divorced spouses, be reduced by two-thirds of the monthly amount of
their own Federal, State, or local government pension. Since two-thirds of your other
pension equals or exceeds the Social Security benefit payable to you as a spouse,
no Social Security benefits are payable at this time.
|
1001.
|
GOVERNMENT PENSION PARTIAL OFFSET
The law requires that monthly benefits payable under Social Security to spouses, including
surviving and divorced spouses, be reduced by two-thirds of the monthly amount of
their own Federal, State, or local government pension. Since you are receiving such
a pension, the Social Security benefit payable on this record to you has been reduced
by $1, two-thirds of the amount of your own Federal, State, or local government pension
as figured on a monthly basis. Your monthly Social Security benefit has been reduced
to $2.
Fill ins:
-
-
|
1376
|
DC DENIAL OR ENGAGING IN SGA - ADVICE REGARDING WORSENING OF CONDITION
If 1 condition gets worse, please contact any Social Security office about filing anther
application
Fill in:
-
|
4000.
|
LEAD IN - MEDICAL IMPROVEMENT CESSATION - TITLE II
We are writing to let you know that we have made a decision on your case. After reviewing
all of the information carefully, we have decided that your health has improved since
we last reviewed your case. And you are now able to work. This means that your benefits
will stop.
|
4001.
|
LEAD IN - GROUP I EXCEPTION - TITLE II
We are writing to let you know that we have made a decision on your case. After reviewing
all of the information carefully, we have decided that you are now able to work. This
means that your benefits will stop.
|
4002.
|
LEAD IN - MEDICARE ONLY - CURRENT COVERAGE - MEDICAL IMPROVEMENT
We are writing to let you know that we have made a decision on your case. After reviewing
all of the information carefully, we have decided that your health has improved since
we last reviewed your case. And you are now able to work. This means that your Medicare
will end.
|
4003.
|
LEAD IN - MEDICARE ONLY - CURRENT COVERAGE - GROUP I EXCEPTION
We are writing to let you know that we have made a decision on your case. After reviewing
all of the information carefully, we have decided that you are now able to work. This
means that your Medicare will end.
|
4004.
|
LEAD IN - MEDICARE ONLY - FUTURE COVERAGE - MEDICAL IMPROVEMENT
We are writing to let you know that we have made a decision on your case. After reviewing
all of the information carefully, we have decided that your health has improved since
we last reviewed your case. And you are now able to work. This means that you cannot
get Medicare.
|
4005.
|
LEAD IN - MEDICARE ONLY - FUTURE COVERAGE - GROUP I EXCEPTION
We are writing to let you know that we have made a decision on your case. After reviewing
all of the information carefully, we have decided that you are now able to work. This
means that you cannot get Medicare.
|
4006.
|
LEAD IN - REOPENING TO CESSATION - MEDICAL IMPROVEMENT - TITLE II
We recently looked at your case again to see if our decision to continue your benefits
was right. After reviewing all of the information carefully, we are changing that
decision. We have decided that your health has improved and you are now able to work.
This means that your benefits will stop.
|
4007.
|
LEAD IN - REOPENING TO CESSATION - GROUP I EXCEPTION - TITLE II
We recently looked at your case again to see if our decision to continue your benefits
was right. After reviewing all of the information carefully, we are changing that
decision. We have decided that you are now able to work. This means that your benefits
will stop.
|
4008.
|
LEAD IN - REOPENING TO CLOSED PERIOD - MEDICAL IMPROVEMENT - TITLE II
We recently looked at your claim again to see if our decision was right. After reviewing
all of the information carefully, we are changing that decision. We have decided that
your health has improved since you were first disabled. And you are now able to work.
This means that your benefits will stop.
|
4009.
|
LEAD IN - REOPENING TO CLOSED PERIOD - GROUP I EXCEPTION - TITLE II
We recently looked at your claim again to see if our decision was right. After reviewing
all of the information carefully, we are changing that decision. We have decided that
you are now able to work. This means that your benefits will stop.
|
4010.
|
LEAD IN - MEDICARE ONLY - REOPENING TO CESSATION - CURRENT COVERAGE - MEDICAL IMPROVEMENT
We recently looked at your case again to see if our decision to continue your Medicare
was right. After reviewing all of the information carefully, we are changing that
decision. We have decided that your health has improved and you are now able to work.
This means that your Medicare will end.
|
4011.
|
LEAD IN - MEDICARE ONLY - REOPENING TO CESSATION - CURRENT COVERAGE - GROUP I EXCEPTION
We recently looked at your case again to see if our decision to continue your Medicare
was right. After reviewing all of the information carefully, we are changing that
decision. We have decided that you are now able to work. This means that your Medicare
will end.
|
4012.
|
LEAD IN - MEDICARE ONLY - REOPENING TO CESSATION - FUTURE COVERAGE - MEDICAL IMPROVEMENT
We recently looked at your claim again to see if our decision was right. After reviewing
all of the information carefully, we are changing that decision. We have decided that
your health has improved since you were first disabled. This means that you cannot
get Medicare.
|
4013.
|
LEAD IN - MEDICARE ONLY - REOPENING TO CESSATION - FUTURE COVERAGE - GROUP I EXCEPTION
We recently looked at your claim again to see if our decision was right. After reviewing
all of the information carefully, we are changing that decision. We have decided that
you are now able to work. This means that you cannot get Medicare.
|
4014.
|
LEAD IN - AUXILIARY NOTICE
We are writing to let you know that we recently reviewed 1's disability case. After reviewing all of the information carefully, we have decided
2 is no longer disabled. When 3 benefits stop, your benefit will also stop.
Fill
ins:
-
-
-
|
4022.
|
LEAD IN - GROUP II EXCEPTION - TITLE II/TITLE XVI
We are writing to let you know that we have made a decision on your case. After reviewing
all of the information carefully, we have decided that you are no longer entitled
to benefits.
|
4038.
|
LEAD IN - LATER CESSATION - MEDICAL IMPROVEMENT - TITLE II
We recently looked at your case to see if the decision we made to stop your benefits
was right. After carefully reviewing all of the information, we found that your health
had not improved and you were not able to work as of 1. But we found that as of 2 your health has improved and you were able to work.
Fill
ins:
-
1.
Month and year of original cessation
-
2.
Month and year of later cessation
|
4040.
|
LEAD IN - BASIS CHANGE ONLY
We recently looked at your case again to see if our decision to continue your benefits
was right. We did this because we got more information on your case. After carefully
reviewing all of the information, we find that the earlier decision was right.
|
4041.
|
REFERRAL TO PERSONALIZED ATTACHMENT
We have enclosed a page that gives more details on how we made the decision on your
case.
|
4043.
|
BENEFITS/PAYMENTS END
When Your
Checks Will
Stop
You are no longer disabled as of 1. You will get checks for that month and the next two months. You last check will
be for 2.
Fill
ins:
-
-
2.
Last month and year of entitlement/eligibility
(1)
|
4044.
|
BENEFITS END - AUXILIARY
When Your Checks Will Stop
1 is no longer disabled as of 2. You will get checks for that month and the next two months. Your last check will
be for 3.
Fill
ins:
-
-
-
3.
Last month and year of entitlement
|
4048.
|
MEDICARE ENDS
When Your Medicare Will End
If you have Medicare, your coverage will end the last day of 1.
Fill
in:
-
1.
Month and year coverage ends. The insert date will be the latest of the following:
-
a.
The month following the month the notice is mailed to the beneficiary, or
-
b.
The last month benefits are payable (item 9c of the SSA-833.
|
4049.
|
MEDICARE ENDS - MEDICARE ONLY
When
Your
Medicare Will
End
You are no longer disabled as of 1. You will be covered for that month and the next two months. Your Medicare coverage
will end the last day of 2.
Fill
ins:
-
-
2.
Month and year coverage ends. The insert date will be the latest of the following:
-
a.
The month following the month the notice is mailed to the beneficiary, or
-
b.
The last month benefits are payable (item 9c of the SSA-833.
|
4051.
|
NO FUTURE MEDICARE COVERAGE
Why You Cannot Get Medicare
You must be disabled for1 months before you can get Medicare. Your disability ended before 1 months. It ended in 2.
Fill
ins:
-
1.
29 (for NH and disabled widow(er) claims)/24 (for disabled child claims)
-
2.
Month and year of termination
|
4052.
|
VOCATIONAL REHABILITATION - TITLE II
If Your Vocational Rehabilitation Is Approved
You told us that you were in a vocational rehabilitation program. If we approve your
program, you will get benefits until you finish it. We will review your program soon.
And we will write you to let you know if it is approved.
|
4054.
|
DDS DECISION
Who Decided Your Case
Doctors and other trained personnel made the disability decision for us. They work
for the State but used our rules to make their decision.
|
4056.
|
RIGHT TO RECONSIDERATION
Do You Think We Are Wrong?
If you think we are wrong you have the right to appeal. We will review this decision
if you appeal.
-
•
You have 60 days to appeal.
-
•
The 60 days start the day after you get this letter. You will need a good reason for
waiting more than 60 days.
-
•
You have to ask for an appeal in writing. Come to one of our offices if you want help.
|
4057.
|
RIGHT TO RECONSIDERATION - DISABILITY CESSATION - SECTION 301 CASE
Do You Think We Are Wrong?
If you think we are wrong, you should appeal now. We will review this decision if
you appeal. Do not wait to see if your vocational rehabilitation program is approved.
-
•
You have 60 days to appeal.
-
•
The 60 days start the day after you get this letter. You will need a good reason for
waiting more than 60 days.
-
•
You have to ask for an appeal in writing. Come to one of our offices if you want help.
|
4059.
|
BENEFIT CONTINUATION - MEDICARE INVOLVED - PRIMARY BENEFICIARY - TITLE II
Appeal in 10 Days to Keep Getting Your Check and Medicare
You have only 10 days to ask us to continue your benefits during your appeal.
-
•
The 10 days start the day after you get this letter.
-
•
You can ask us to keep paying you and your family and/or continue your Medicare.
-
•
If you lose your appeal, you might have to pay back some or all of this money, but
you will not have to pay back Medicare.
|
4060.
|
BENEFIT CONTINUATION - AUXILIARY
Contact Us in 10 Days to Keep
Getting
Your
Check
You have only 10 days to ask us to continue your checks during your appeal. The 10
days start the day after you get this letter.
-
•
Both you and 1 must ask for your checks to continue.
-
•
And either you or 1 must file an appeal.
-
•
If the appeal is lost, you might have to pay back some or all of the money you got.
Fill
in:
-
|
4063.
|
BENEFIT CONTINUATION - MEDICARE INVOLVED - LATER CESSATION OR BASIS CHANGE ONLY
Appeal in 10 Days to Start Getting Your Check and
Medicare
You have only 10 days to ask us to start your benefits again during your appeal.
-
•
The 10 days start the day after you get this letter.
-
•
You can ask us to keep paying you and your family and/or start your Medicare.
-
•
If you lose your appeal, you might have to pay back some or all of this money, but
you will not have to pay back Medicare.
|
4064.
|
BENEFIT CONTINUATION - AUXILIARY
Contact Us in 10 Days to Start Getting Your Check
You have only 10 days to ask us to start your checks during your appeal. The 10 days
start the day after you get this letter.
-
•
Both you and 1 must ask for your checks to start again. And either you or 1 must file an appeal.
-
•
If the appeal is lost, you might have to pay back some or all of the money you got.
Fill
in:
-
|
4066.
|
DISABILITY HEARING INFORMATION
How An Appeal Works
A Disability Hearing Officer will decide your appeal. We will call this person a DHO
in the rest of our letter. The DHO will meet with you before making the decision on
your appeal. The meeting works like this.
-
•
The DHO will write you about the time and place for the meeting.
-
•
You can look at you file before the meeting.
-
•
You can tell the DHO why you think you are still disabled. You can give the DHO more
facts. And you can bring people to say why you are disabled.
-
•
You can have the DHO ask people to come to the meeting and bring important papers.
You can question these people at the meeting.
-
•
You do not have to go to the meeting in person. If you do not want to go, you can
give the DHO more facts you may have. The DHO will decide your case using these facts,
and what is now in your file. But if you go to the meeting, it may help the DHO decide
your case.
|
4069.
|
IF YOU NEED HELP WITH YOUR APPEAL
If You
Want Help
With Your
Appeal
You may want help from a friend, lawyer or someone else. There are groups that can
find you a lawyer. Some can give you a free lawyer. We can give you the names of these
groups.
|
4070.
|
THINGS TO REMEMBER - TITLE II
If
Your Health
Gets
Worse
If your health gets worse and you feel that you are disabled again, please get in
touch with us. You may be able to get benefits again.
|
4071.
|
THINGS TO REMEMBER - MEDICARE - CURRENT COVERAGE
If Your Health Gets Worse
If your health gets worse and you feel that you are disabled again, please get in
touch with us. You may be able to get Medicare again.
|
4072.
|
THINGS TO REMEMBER - MEDICARE - FUTURE COVERAGE
If Your Health Gets Worse
If your health gets worse and you feel that you are disabled again, please get in
touch with us. You may be able to file for Medicare again.
|
4078.
|
DO REFERRAL
If You Have Any Questions
If you have any questions, you should call, write, or visit any Social Security office.
If you visit an office, please bring this letter. It will help us answer your questions.
|
4080.
|
DIB, DI or CDB MEDICAL CESSATION – TITLE II AND XVI
Your health has improved and you are able to start working in 1.
Fill
in:
-
1.
Month and year disability ceased
|
4081.
|
DISABILITY CESSATION - CLEAR CUT - TITLE II
When you became entitled to benefits, we expected that your health might improve.
The evidence in your case shows that you health has improved and you became able to
work starting in 1.
Fill
in:
-
1.
Month and year disability ceased.
|
4082.
|
DIB, DWB OR CDB CESSATION - WHEREABOUTS UNKNOWN OR FAILURE TO COOPERATE - REQUIRED
INFORMATION NOT SUBMITTED - TITLE II
We need information to decide whether you are still disabled. We asked you to furnish
the information but it has not been received. Therefore, we have decided that your
disability ended in 1.
Fill in:
-
1.
Month and year disability ceased
|
4083.
|
DIB, DWB OR CDB CESSATION - WHEREABOUTS UNKNOWN OR FAILURE TO COOPERATE - REQUESTED
MEDICAL EXAMINATION NOT TAKEN - TITLE II
We need information to decide if you are still disabled. We asked you to take a special
medical examination at our expense but you have not done so. Therefore, we have decided
that your disability ended in 1.
Fill
in:
-
1.
Month and year disability ceased
|
4084.
|
MEDICAL CESSATION - ADVANCES IN MEDICAL THERAPY OR TECHNOLOGY - TITLE II/TITLE XVI
Your ability to work has been helped by new medical or rehabilitative treatments that
you have received. These treatments allow you to work starting in 1.
Fill
in:
-
1.
Month and year disability ceased
|
4085.
|
MEDICAL CESSATION - ADVANCES IN VOCATIONAL THERAPY OR TECHNOLOGY - TITLE II/TITLE
XVI
Your ability to work has been helped because you have undergone vocational therapy.
This therapy includes any additional education, counseling, training or work experience
you have received. This therapy allows you to work starting in 1.
Fill
in:
-
1.
Month and year disability ceased
|
4086.
|
MEDICAL CESSATION - NEW OR IMPROVED DIAGNOSTIC OR EVALUATIVE TECHNIQUES - TITLE II/TITLE
XVI
Based on new or improved diagnostic or evaluative methods your health is not as bad
as it was considered to be at the time of the most recent favorable medical decision.
You can work starting in 1.
Fill
in:
-
1.
Month and year disability ceased
|
4087.
|
CESSATION - PRIOR DETERMINATION IN ERROR - TITLE II/TITLE XVI
The evidence we considered in making your prior favorable decision shows that an error
was made. You can work starting in 1.
Fill
in:
-
1.
Month and year disability ceased
|
4088.
|
CESSATION - FRAUD - TITLE II/TITLE XVI
You obtained a prior favorable determination by fraud. You are not considered disabled
starting in 1.
Fill
in:
-
1.
Month and year disability ceased
|
4095.
|
FAILURE TO FOLLOW PRESCRIBED TREATMENT - TITLE II/TITLE XVI
You are not following medical treatment that would improve your health and make you
able to work. Therefore, you are not considered disabled starting in 1.
Fill
in:
-
1.
Month and year disability ceased
|
4096.
|
DWB MEDICAL CESSATION - TITLE II
Your health has improved. You no longer meet the special medical rules to get disabled
widow(er)'s benefits starting in 1.
Fill
in:
-
1.
Month and year disability ceased
|
4097.
|
BENEFIT CONTINUATION RIGHTS - MEDICARE NOT INVOLVED
You have only 10 days to ask us to continue your checks during your appeal.
-
•
The 10 days start the day after you get this letter.
-
•
Also, if you ask us to keep paying you and you are covered by Medicare, your Medicare
will continue.
-
•
If you lose your appeal, you might have to pay back some or all of this money, but
you will not have to pay back Medicare.
|
4098.
|
APPEAL RIGHTS - FACE-TO-FACE HEARING - REOPENING TO A LATER ONSET
Do You Think We Are Wrong?
If you think we are wrong, you have the right to appeal. People who have not seen
your case before will look at it. These people work for an agency of your State. They
may find that you were disabled earlier. If they do not, your case will then be sent
to a Disability Hearing Officer. In the rest of this letter we will call this person
a DHO. The DHO will correct mistakes and look at any more facts you have. We call
this a disability hearing.
-
•
You have 60 days to appeal.
-
•
The 60 days start the day after you get this letter.
-
•
You will have to have a good reason for waiting more than 60 days.
-
•
You have to ask for a disability hearing in writing. Come to one of our offices if
you want help.
NOTE: Delete caption when used on award notices.
|
4104.
|
APPEAL RIGHTS - ALJ HEARING - TITLE II
Do You Think We Are Wrong?
If you think we are wrong, you have the right to appeal. A person who has not seen
your case will look at it. That person will be an administrative law judge. In the
rest of our letter we will call this person an ALJ. The ALJ will correct mistakes
and look at any new facts you have before deciding your case. We call this a hearing.
-
•
You have 60 days to ask for a hearing.
-
•
The 60 days start the day after you get this letter.
-
•
You will have to have a good reason for waiting more than 60 days to ask for a hearing.
|
4115.
|
BENEFITS END - LATER CESSATION
How This Affects Your Checks
-
•
You are no longer disabled as of 1.
-
•
You are due checks for that month and the next two months.
-
•
Your last check will be for 2.
-
•
If you are due back checks, we will write you soon about the money we owe you.
Fill
ins:
-
1.
Month and year of cessation
-
2.
Month and year of termination
|
4116.
|
LEAD IN - REOPENING TO LATER CESSATION - NO MEDICAL IMPROVEMENT - TITLE II
We recently looked at your case to see if the decision we made to stop your benefits
was right. After carefully reviewing all of the information, we found that you were
not able to work as of 1. But we found that as of 2 you were able to work.
Fill
ins:
-
1.
Month and year of original cessation
-
2.
Month and year of later cessation
|
4127.
|
LEAD IN - REOPENING TO CESSATION - GROUP II EXCEPTION - TITLE II
We recently looked at your case to see if our decision to continue your benefits was
right. After reviewing all of the information carefully, we are changing that decision.
We have decided that you are no longer entitled to benefits.
|
4131.
|
RIGHT TO RECONSIDERATION (FOREIGN CLAIMS)
Do You Think We Are Wrong?
If you think we are wrong, you have the right to appeal. People at the International
Program Service Center who have not seen your case before will look at it. These people
work for an agency of your State. They may find that you are disabled. If they do
not, your case will then be sent to a Disability Hearing Officer. In the rest of our
letter we will call this person a DHO. The DHO will correct mistakes and look at any
more facts you have. We call this a disability hearing.
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•
You have to ask for a disability hearing in writing.
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•
You have 60 days to ask for a disability hearing.
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•
The 60 days start the day after you get this letter.
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•
Disability hearings are held in the United States. If you come for your disability
hearing, the trip to the United States will be at your own expense.
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4132.
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RIGHT TO RECONSIDERATION - AUXILIARY (FOREIGN CLAIM)
Do You Think We Are Wrong?
If you think we are wrong, you have the right to appeal. If you appeal, you can have
a face-to-face hearing before a Disability Hearing Officer.
-
•
You have 60 days to ask for a disability hearing.
-
•
The 60 days start the day after you get this letter.
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•
You will have to have a good reason for waiting more than 60 days.
-
•
Disability hearings are held in the United States. If you come for your disability
hearing, the trip to the United States will be at your own expense.
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4133.
|
RIGHT TO RECONSIDERATION - AWARD NOTICE - REVISION TO LATER ONSET (FOREIGN CLAIM)
If you think we are wrong, you have the right to appeal. You have 60 days to ask for
an appeal. The 60 days start the day after you get this letter. You will have to have
a good reason for waiting more than 60 days. You have to ask for an appeal in writing.
If you think you were disabled earlier, the appeal works like this. People at the
International Program Service Center who have not seen your case before will look
at it. They may find that you were disabled earlier. If they do not, your case will
then be sent to a Disability Hearing Officer. In the rest of this letter we will call
this person a DHO. The DHO will correct mistakes and look at any more facts you have.
We call this a disability hearing. Disability hearings are held in the United States.
If you come for your disability hearing, the trip to the United States will be at
your own expense.
A disability hearing works like this. The DHO will tell you the time and place for
the disability hearing. You can look at your file before the disability hearing. The
DHO will explain the law in your case. The DHO will state the known facts and tell
you what is to be decided. You can tell the DHO why you think we are wrong. You can
give the DHO more facts. You can bring people to say why you are right. The DHO can
ask people to come to your disability hearing and bring important papers. You can
question these people at your disability hearing. You do not have to go to the disability
hearing in person. If you want, you can give the DHO more facts you may have. The
DHO will decide your case using these facts and what is now in your file. But if you
go to the disability hearing, it may help the DHO decide your case.
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4134.
|
GENERAL CLOSING PARAGRAPH (FOREIGN CLAIM)
If You Have Questions or
Want to
Appeal
-
•
If you live in the United States, British Virgin Islands, Canada or Western Samoa, contact any Social Security office.
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•
If you live in Mexico, contact any Social Security office of the nearest United States
Embassy or consulate.
-
•
If you live in the Philippines, contact the Veterans Administration Regional Office,
Social Security Division, 1131 Roxas Boulevard, Manila.
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•
In all other countries, get in touch with the nearest United States Embassy or consulate.
You may also write to the Social Security Administration, P.O. Box 17769, Baltimore,
Maryland 21203, U.S.A. Please be sure to include your claim number if you do write.
However, if you visit an office please take this letter. It will help the people there
answer your questions. (Form Notice.)
or
If You Have Questions or Want to Appeal
If you have any questions or want to appeal, you should contact (see fill-ins). You
may also write to the Social Security Administration, P.O. Box 17769, Baltimore, Maryland
21203, U.S.A.
Please be sure to include your claim number if you do write. However, if you visit
an office, please bring this letter. It will help the people there answer your questions.
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|
Fill
ins:
A. If the consular code is 600 or 601, then show:
“The Veterans Administration Regional Office Social Security Division, 1131 Roxas Boulevard, Manila.”
B. If the consular code is 953, 815 or 816, then show:
“any Social Security office.”
C. If the consular code is 704, 714, 734, 754, 773, 774, 783, 793 or 899, then show:
“any Social Security office or the nearest United States Embassy or consulate.”
D. If the geographic code is 10120A, 50160A or 33020E, then show:
“any Social Security office or the nearest United States Embassy or consulate.”
E. If the geographic code is 05480A, then show:
“any Social Security office or the nearest United States Embassy or consulate. Or,
if you live in the Philippines, you may contact the Veterans Administration Regional
Office, Social Security Division, 1131 Roxas Boulevard, Manila.”
F. If consular or geographic code is other than shown above, then show:
“the nearest United States Embassy or consulate.” (Word Processing Notice)
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4135.
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DISABILITY HEARING INFORMATION (FOREIGN CLAIM)
How An Appeal Works
A Disability Hearing Officer will decide your appeal. We will call this person a DHO
in the rest of our letter. The DHO can meet with you before making the decision on
your appeal. The meeting works like this.
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•
The DHO will write you about the time and place for the meeting. It will be held in
the United States.
-
•
You can look at your file before the meeting.
-
•
You can tell the DHO why you think you are still disabled. You can give the DHO more
facts. And, you can bring people to say why you are disabled.
-
•
You can have the DHO ask people to come to the meeting and bring important papers.
You can question these people at the meeting.
-
•
You do not have to go to the meeting in person. If you do not want to go, you can
give the DHO more facts you may have. The DHO will decide your case using these facts,
and what is now in your file.
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4158.
|
AUXILIARY NOTICE - LEAD IN - ALLOWANCE TO DENIAL
We recently looked at 1's disability case again to make sure that our decision was right. After reviewing
all of the information carefully, we are changing our decision. We now find that 2 was not disabled. Therefore, your claim is denied. You will get another letter soon
about when your checks will stop.
Fill
ins:
-
-
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4159.
|
LEAD IN - ALLOWANCE TO DENIAL - TITLE II
We recently looked at your disability claim again to make sure that our decision was
right. After reviewing all of the information carefully, we are changing our decision.
We now find that you are not disabled. Therefore, your claim is denied. You will get
another letter soon about when your checks will stop.
|
4160.
|
RIGHT TO RECONSIDERATION - AWARD NOTICE
If you think we are wrong, you have the right to appeal. You have 60 days to ask for
an appeal. The 60 days start the day after you get this letter. You will have to have
a good reason for waiting more than 60 days. You have to ask for an appeal in writing.
Come to one of our offices if you want help. If you think you were disabled earlier,
the appeal works like this. People who have not seen your case before will look at
it. These people work for an agency of your State. They may find that you were disabled
earlier. If they do not, your case will then be sent to a Disability Hearing Officer.
In the rest of this letter we will call this person a DHO. The DHO will correct mistakes
and look at any more facts you have. We call this a disability hearing.
A disability hearing works likes this. The DHO will tell you the time and place for
the disability hearing. You can look at your file before the disability hearing. The
DHO will explain the law in your case. The DHO will state the known facts and tell
you what is to be decided. You can tell the DHO why you think we are wrong. You can
give the DHO more facts. You can bring people to say why you are right. The DHO can
ask people to come to your disability hearing and bring important papers. You can
question these people at your disability hearing. You do not have to go to the disability
hearing in person. If you want, you can give the DHO more facts you may have. The
DHO will decide your case using these facts and what is now in your file. But if you
go to the disability hearing, it may help the DHO decide your case.
If you have questions about your claim, you may get in touch with any Social Security
office. Most questions can be handled by telephone or mail. If you visit an office,
however, please take this letter with you.
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4170.
|
LEAD IN - AFFIRMATION OF A DENIAL
We recently looked at your claim to see if our decision that you are not disabled
was right. After carefully reviewing all of the information, we again find that you
are not disabled. This means that you will not get disability checks.
|
4171.
|
LEAD IN - AFFIRMATION OF A LATER ONSET
We recently looked at your claim to see if your disability began before 1. After carefully reviewing all of the information, we again find that you were disabled
as of 1. This means that you will not get any back checks, and the check you get now will
not change.
Fill
in:
-
|
4172.
|
LEAD IN - AFFIRMATION OF A CLOSED PERIOD
We recently looked at your claim to see if your disability continued after 1. After carefully reviewing all of the information, we again find that you were disabled
from 2 to 1. This means that you will not get any more checks.
Fill
ins:
-
-
|
4173.
|
APPEAL OF THE EARLIER DECISION
About
Your Appeal
of the Earlier
Decision
You appealed the earlier decision on your claim. The administrative law judge did
not make a decision, but instead told us to look at your claim again using new information.
|
4175.
|
DDS DECISION - FOREIGN VERSION
Who Decided Your Case
Our doctors and other trained personnel made the disability decision in your case.
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4176.
|
APPEALS RIGHTS - ALJ HEARING FORMAL REMANDS
Do You Think We Are Wrong?
If you think we are wrong, you have the right to appeal again. An administrative law
judge will look at your claim. In the rest of our letter we will call this person
an ALJ. The ALJ will correct mistakes and look at any new facts you have before deciding
your case. We call this a hearing.
-
•
You have 60 days to ask for a hearing.
-
•
The 60 days start the day after you get this letter.
-
•
You will have to have a good reason for waiting more than 60 days to ask for a hearing.
-
•
You have to ask for a hearing in writing. Contact one of our offices if you want help.
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4177.
|
HOW AN ALJ HEARING WORKS
How a Hearing Works
A hearing works like this:
-
•
The ALJ will tell you the time and place for the hearing.
-
•
The ALJ will explain the law in your case. The ALJ will state the known facts and
tell you what has to be decided.
-
•
You can tell the ALJ why you think we are wrong. You can give the ALJ more facts.
And you can bring people to say why you are right.
-
•
The ALJ can make people come to your hearing and bring important papers. You can question
these people at the hearing.
-
•
We will ask if you want to go to the hearing in person. If you say you want to go,
you should attend it if at all possible. If you change your mind or if you cannot
get to the hearing you should tell us. You should know that your being there may help
the ALJ decide your case.
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4178.
|
HOW AN ALJ HEARING WORKS - FOREIGN VERSION
How a Hearing Works
A hearing works like this:
-
•
The ALJ will tell you the time and place for the hearing.
-
•
The ALJ will explain the law in your case. The ALJ will state the known facts and
tell you what has to be decided.
-
•
You can tell the ALJ why you think we are wrong. You can give the ALJ more facts.
And you can bring people to say why you are right.
-
•
The ALJ can make people come to your hearing and bring important papers. You can question
these people at the hearing.
-
•
We will ask if you want to go to the hearing in person. If you say you want to go,
you should attend it if at all possible. If you change your mind or if you cannot
get to the hearing you should tell us. You should know that your being there may help
the ALJ decide your case.
-
•
You can only have a hearing in the United States. You would have to pay any costs
for traveling to the United States for a hearing.
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