This section provides facsimiles of the Form SSA-2568-U3 and the 2568/256C administrative message screens.

This is an exhibit of the PC Reply - 2568 and 256C.

ADM       PC REPLY         2568

     TRANSFER TO:

ROUTING INDICATOR (TO):    DATE (MMDDYY):      NH NAME:

SSN:      BIC:      BENEFICIARY NAME:

CROSS REFERENCE SSN/BIC:

FROM

•  

  PC:      PC CONTACT PERSON:
  
  PHONE:      FAX:
  
  TYPE OF REPLY:    1= FINAL    2= INTERIM

   

TO

•  

  DISTRICT OFFICE (CITY/STATE):
  
  DO CONTACT PERSON:         UNIT:

   

TYPE OF REQUEST RECEIVED:

•  

  1 = CRITICAL 2489    2 = PRIORITY 2560      3 = NONPRIORITY 2560

DATED (MMDDYY):

REQUESTING

1 = CRITICAL PAY   2 = EXPEDITED PAYMENT   3 = ACTION   4 = INFORMATION 5 = FOLLOWUP

BENEFICIARY CONTACTED DIRECTLY (Y/N):

                                    2568 PAGE 2

EXPLANATION

•  

  1 = PAYMENT ACTION TAKEN

  2 = REQUEST IS BEING EXPEDITED - WILL ADVISE AS SOON AS POSSIBLE

  3 = NO RECORD OF THIS SSN - PLEASE VERIFY AND RESUBMIT REQUEST

  4 = CLAIM NOT IN THIS OFFICE - RETRANSMIT REQUEST TO PROPER PC

  5 = EXCLUDED FROM THE CRITICAL PROCESS PER POMS RS 02801.000 ff.

  6 = NO PAYMENT ACTION DUE - SEE EXPLANATION BELOW

  7 = ACTION CANNOT BE TAKEN WITHOUT THE FOLDER - SEE EXPLANATION BELOW

  8= OTHER

IF 1 IS SELECTED ENTER PAYMENT INFORMATION:

BIC:      PAID AMT:       FOR:       RUN (MMDD):       CONT AMT:

BIC:      PAID AMT:       FOR:       RUN (MMDD):       CONT AMT:

BIC:      PAID AMT:       FOR:       RUN (MMDD):       CONT AMT:

BIC:      PAID AMT:       FOR:       RUN (MMDD):       CONT AMT:

CASE INFORMATION:

This is an exhibit of the Form SSA-2568-U3.

PC Reply, MSOM ADMIN 004.004 and MSOM ADMIN 004.005

Introduction to TRIDE System, MSOM DOORS 001.001

Routing Indicator Directory(RID), MSOM DOORS 002.003

TRIDE Input Screens, MSOM DOORS 003.001