TN 25 (06-18)
What We Will Pay And When
(1) Payment of $ (2)
Fill-ins:
(1) “Your”/SN possessive
(2) Amount of payment
(1) Regular Monthly Payment
Fill-in:
(1) “Your”/SN possessive
(1) Payment of $ (2)
Fill-ins:
(1) “Your”/SN possessive
(2) Amount of first payment
Why We Cannot Pay Current Benefits
Why We Cannot Pay Past Benefits
PAYR01 Partial Award
We used (1) (2) to decide how much to pay (3) . We are still working on (4) claim. When we make a final decision about the (5) , we will figure the amount of (6) payments. We will send (7) another letter to let (8) know if there will be any change in (9) payments.
Fill-ins:
(1) “your”/Beneficiary's FN possessive
(2) dictated text *
(3) “you”/“her”/“him”
(4) “your”/“her”/“his”
(5) dictated text *
(6) “your”/“her”/“his”
(7) “you”/“her”/“him”
(8) “you”/“her”/“him”
(9) “your”/“her”/“his”
(*) indicates that the fill-in is manual
PAY002 PMA or CMA Different From Ongoing Amount
You will receive $ (1) around (2) .
Fill-ins:
(1) Amount of first payment
(2) Month, day and year of expected receipt
PAY003 Payment Months (Concluding Sentence for PAY002)
This is the (1) money (2) (3) due for (4) (5) (6) .
Fill-ins:
(1) null
(2) “you”/SN/FN/First Name
(3) “are”/“is”
(4) month and year
(5) “and”/“through”/null
(6) month and year/null
PAY004 Current or Deferred Benefits Due
You will receive $ (1) for (2) around (3) .
Fill-ins:
(1) Payment amount
(2) Month and year payment is due
(3) Month, day and year of expected receipt
PAY006 Medical Insurance Premium Deduction
The above amounts may change because of medical insurance premium deductions.
PAY009 Ongoing Benefit Amount
(1) After that you will receive $ (2) (3) (4) (5) .
Fill-ins:
(1) null/“You will receive”
[1a] for [1b].
[1a] Money fill-in
[1b] Date fill-in the format “September 1995”
(2) Money fill-in
(3) “on or about the”/“for”/“through”
(4) “third”/“second Wednesday”/“third Wednesday”/“fourth Wednesday”/Date in the format “July 1994”
(5) “of each month”/null
PAY012 Payment Through Direct Deposit
(1) and any future payments will go to the financial institution you selected. Please
let us know if you change your mailing address, so we can send you letters directly.
Fill-in:
(1) “These”/“This”
PAY013 Monthly Credited Amount Less than One Dollar
(1) monthly benefits are less than a dollar. So, we will not pay you a check each month.
We will hold the monthly benefits (2) due and pay you this money at the end of the year.
Fill-ins:
(1) “Your”/SN possessive/FN possessive/First Name possessive
(2) “you are”/“she is”/“he is”
PAY018 Summary Sheet Included
Later in this letter, we will show you how we figured (1) (2) .
Fill-ins:
(1) null
(2) “this amount”/“these amounts”
PAY019 Summary Sheet - Introduction
Here is how we figured (1) (2) (3) :
Fill-ins:
(1) “your”/FN possessive
(2) “first payment”
(3) null
PAY020 Summary Sheet – Benefits Due
Benefits due for (1) . . . . . . . . . . . . . . (2)
Fill-ins:
(1) month and year
(2) null/“,”
PAY022 Summary Sheet – Subtraction Explanation
(1) we subtracted because (2)
Fill-ins;
(1) “Amount”/“Amounts”
(2) “of:”/“of”
PAY023 Summary Sheet - Introduction
Here is how we figured (1) (2) effective (3) :
Fill-ins:
(1) FN possessive/“your”
(2) “regular monthly payment”
(3) Month and year
PAY024 Summary Sheet – Monthly Benefit Amount
(1) entitled to a monthly benefit of (2) . . . . . . . (3)
Fill-ins:
(1) “You are”/“She is”/“He is”
(2) null/variable length ellipsis
(3) MBA amount
PAY025 Summary Sheet – Monthly Payment Amount
This equals the amount of (1) (2) (3) (4)
Fill-ins:
(1) SN possessive/“your”
(2) “first payment”
(3) variable length ellipsis
(4) Money amount
PAY026 Summary Sheet - Introduction
Here is how we figured (1) (2) benefits:
Fill-ins:
(1) FN possessive/“your”
(2) “current”/“past”
How (1) Benefits Can Be Paid
Fill-in:
(1) Beneficiary's name (possessive)/Your
PAY027 Summary Sheet – Subtraction Explanation
(1) we must subtract because (2) .
Fill-ins:
(1) “Amount”/“Amounts”
(2) “of”/“of:”
PAY028 Summary Sheet – Conditional Award Total
This equals . . . . . . . . . . . . . . .$00.00
PAY030 Combined Check
(1) benefit is $ (2) on (3) earnings record and $ (4) as a (5) .
Fill-ins:
(1) “Your”/“Her”/“His”
(2) Money fill-in
(3) “your”/“her”/“his”
(4) Money fill-in
(5) Type of benefit
PAY032 Auxiliary/Survivor Awarded after Primary
(1) benefit is $ (2) as a (3) . This is in addition to the benefit of $ (4) on (5) own earnings record.
Fill-ins:
(1) “Your”/“Her”/“His”
(2) Money fill-in
(3) Type of benefit
(4) Money fill-in
(5) “your”/“her”/“his”
PAY033 Technical Entitlement – PMA Only Due in Addition to Regular Payment
(1) will also receive a payment of $ (2) for (3) . This is the only money (4) due on (5) record.
Fill-ins:
(1) “He”/“She”/“You”
(2) Money fill-in
(3) Date fill-in
(4) “he is”/“she is”/“you are”
(5) “his”/“her”/“your”
PAY041 Summary Sheet – SMI Arrearage
Additional amount we subtracted for medical insurance premium due one month in advance
(1) .
Fill-in:
(1) Premium amount
PAY042 Summary Sheet – Benefits Due
Benefits due for (1) . . . . (2) . . . . (3)
Fill-ins:
(1) Month and year
(2) null or variable length ellipsis
(3) Amount
PAY043 Payment Months (Concluding Sentence for PAY002, Two Periods of Payment)
This is the (1) money (2) due for (3) (4) (5) and (6) (7) (8) .
Fill-ins:
(1) null
(2) “you are”/“she is”/“he is”
(3) Month and year
(4) “and”/“through”/null
(5) Month and year/null
(6) Month and year
(7) “and”/“through”/null
(8) Month and year/null
PAY044 Payment Months (Concluding Sentence for PAY002, Three Periods of Payment)
This is the (1) money (2) due for (3) (4) (5) , (6) (7) (8) and (9) (10) (11) .
Fill-ins:
(1) null
(2) “you are”/“she is”/“he is”
(3) Month and year
(4) “and”/“through”/null
(5) Month and year/null
(6) Month and year
(7) “and”/“through”/null
(8) Month and year/null
(9) Month and year
(10) “and”/“through”/null
(11) Month and year/null
PAY045 Payment Months (Concluding Sentence for PAY002, Four Periods of Payment)
This is the (1) money (2) due for (3) (4) (5) , (6) (7) (8) , (9) (10) (11) and (12) (13) (14) .
Fill-ins:
(1) null
(2) “you are”/“she is”/“he is”
(3) Month and year
(4) “and”/“through”/null
(5) Month and year/null
(6) Month and year
(7) “and”/“through”/null
(8) Month and year/null
(9) Month and year
(10) “and”/“through”/null
(11) Month and year/null
(12) Month and year
(13) “and”/“through”/null
(14) Month and year/null
PAY046 Summary Sheet – Work Deductions (Use with PAY022)
(1) work (2) (3)
Fill-ins:
(1) NH FN possessive/“Your”
(2) null/variable length ellipsis
(3) Amount
PAY047 Summary Sheet – Maritime Tax Subtraction (Use with PAY022)
unpaid Social Security taxes due for (1) maritime taxes. . . . (2)
Fill-ins:
(1) FN possessive/“your”
(2) Amount
PAY048 Summary Sheet – SMI Premium Subtraction (Use with PAY022)
premiums for medical insurance . . . . . . . . . . (1)
Fill-in:
(1) Amount of premiums
PAY049 Summary Sheet - Subtotal
This equals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(1)
PAY050 Summary Sheet - Rounding
rounding [we must round down to a whole dollar] . . . . . (1)
Fill-in:
(1) Rounding amount
PAY051 Summary Sheet – Attorney Fee Withholding (Use with PAY022)
money to pay (1) lawyer . . . . . . . . . . (2) . . . . . . . . (3)
Fill-ins:
(1) FN possessive/“your”
(2) Variable length ellipsis/null
(3) Attorney fee withholding amount
PAY052 Summary Sheet – Alien Tax Withholding (Use with PAY022)
U.S. Federal taxes due on (1) Social Security (2) (3)
Fill-in:
(1) FN possessive/“your”
(2) null/variable length ellipsis
(3) Amount of tax withheld
PAY053 Summary Sheet – Total Subtractions (Use with PAY022)
Total subtractions . . . . . . . . . . . . . . . . . . (1)
PAY054 Summary Sheet – Alien Non-payment (Use with PAY022)
(1) residence outside of the U.S . . . . . . . . . (2)
Fill-ins:
(1) FN possessive/“your”
(2) Amount
PAY055 Summary Sheet – Prisoner Suspension (Use with PAY027)
(1) conviction of a felony . . . . . . . . . . . . (2)
Fill-ins:
(1) FN possessive/“your”
(2) Amount withheld
PAY056 Summary Sheet – Work Deduction (Use with PAY027)
(1) work and earnings over the limit . . . . . . . (2)
Fill-ins:
(1) FN possessive/“your”
(2) Amount deducted
PAY057 Summary Sheet – Medical Insurance (Use with PAY027)
premiums for medical insurance . . . . . . . . . . (1)
Fill-in:
(1) Premium amount withheld
PAY058 Summary Sheet (Use with PAY020)
(1) (2) (3)
Fill-ins:
(1) “and”/“through”
(2) Month and year
(3) “,”/null
PAY059 Summary Sheet (Use with PAY020)
including any cost of living increase (1) (2)
Fill-ins:
(1) “and”/null
(2) “,”/null
PAY060 Summary Sheet (Use with PAY020)
considering work and earnings through (1)
PAY061 Summary Sheet (Use with PAY042)
(1) (2) (3) (4)
Fill-ins:
(1) “and”/“through”
(2) Month and year
(3) null/variable length ellipsis
(4) Amount/null
PAY062 Summary Sheet (Use with PAY042)
with premiums for medical insurance deducted $ (1)
PAY063 Summary Sheet
less monthly rounding of benefits $ (1)
PAY064 Summary Sheet
premiums for medical insurance through (1) (2) (3)
Fill-ins:
(1) Month and year (COM)
(2) null/variable length ellipsis
(3) Amount
PAY065 Summary Sheet
additional premium due one month in advance . . . . $ (1)
PAY066 Summary Sheet
government pension offset . . . . . . . . . . . . . $ (1)
PAY067 Payment Prior to Completion of Claim/PMA Exists
We will subtract $ (1) from your next check. This is the amount we paid you before we finished work on (2) claim.
Fill-ins:
(1) CPA in format $$,$$$.¢¢
(2) “your”/FN (Possessive)
PAY068 Payment Prior to Completion of Claim/Equal to PMA
When we figured how much to pay you through (1) , we subtracted the money which we already paid you while we finished work on (2) claim.
Fill-ins:
(1) If LAF equals C: CMA minus one month in format January 1993. If LAF does not equal
C: find first EFD with equal RFD to current LAF and is greater than DOEC. This fill-in
is EFD minus one month in format January 1993.
(2) “your”/FN (Possessive)
PAY069 Summary Sheet
amount paid before work was finished on claim . . . . . . $ (1)
Fill-in:
(1) CPA in format $$,$$$.¢¢
PAY072 Regular Monthly Payment When DAA/Installment Present
This check includes (1) regular monthly payment of (2) for (3) .
Fill-ins:
(1) “your”/“her”/“his”
(2) Money amount in format $$$.¢¢
(3) Month/year
PAY073 DAA Past Due Benefits and Installment
(1) still due back payments of $ (2) for past months. (3) will receive this money over a period of months. We will send (4) $ (5) more each month with (6) regular payment until all of the extra money is paid.
Fill-ins:
(1) “You are”/“She is”/“He is”
(2) Amount of past due benefit payable
(3) “you”/“she”/“he”
(4) “you”/“her”/“him”
(5) Amount of installment payment
(6) “your”/“her”/“his”
PAY074 Voluntary Tax Amount Withheld
voluntary withholding for Federal taxes.....................$ (1)
Fill-in:
(1) Amount withheld for voluntary Federal tax withholding
PAY088 Payment Cycling
(1) next payment of $ (2) , which is for (3) , will be received on or about the (4) of (5) .
Fill-ins:
(1) “Your”/beneficiary's FN possessive
(2) MBP in the format “$$$$$.¢¢”
(3) COM in the format “June 1998”
(4) third/second Wednesday/third Wednesday/fourth Wednesday
(5) COM + 1, in the format “June 1998”
PAY090 Summary Sheet (DE) Amount of Benefit on Other SSN
(1) also entitled to a monthly benefit of......... (2) ......... (3)
Fill-ins:
(1) “You are”/“She is”/ “He is”
(2) Variable length ellipsis
(3) Money Fill-in
PAY161 LAF is C but the CMA is $0.00
No payment is due at this time because of adjustments made to (1) benefits.
Fill-in:
(1) “her”/“his”/“your”