TN 9 (05-02)

GN 03106.099 Exhibits

Exhibit A – Return of Service of Summons by Mail

Exhibit B - To Whom It May Concern

Exhibit C – Court Remand Flag

Exhibit D – “Halt Effectuation” Memorandum

Exhibit E – “Resume Effectuation” Memorandum

Exhibit F – 95-Day Effectuation Delay Letter

Exhibit A - Return of Service of Summons by Mail

Service of the Summons and Complaint was made by

DATE

NAME OF SERVER (Print)

TITLE

Check one box below to indicate appropriate method of service

[ ] Served personally upon the defendant. Place where served:

     _________________________________________________________________

[ ] Left copies thereof at the defendant's dwelling house or usual place of abode with a person      of suitable age and discretion then residing therein.

     Name of person with whom the summons and complaint were left:

   ________________________________________________________________

[ ] Returned unexecuted: _________________________________________

     __________________________________________________________________

     __________________________________________________________________

     _________________________________________________________________

[ ] Other (specify): _______________________________________________

__________________________________________________________________

__________________________________________________________________

STATEMENT OF SERVICE FEES

TRAVEL

SERVICES

TOTAL

DECLARATION OF SERVER

I declare under penalty of perjury under the laws of the United States of America that the foregoing information contained in the Return of Service and Statement of Service Fees is true and correct.

Executed on______________________ __________________________

                      Date                                                                                       Signature of Server

___________________________

Address of Server

EXHIBIT B - TO WHOM IT MAY CONCERN:

The following Social Security benefits were certified for payment to (name of payee)

under Social Security claim number ___ ___ ___ - ___ ___ - ___ ___ ___ ___

for the period (mm/yy) to (mm/yy).

Approximate Date of PaymentsPayment AmountsMedicare Premiums

January 2, 1996

$ 798.00

$ 42.50

February 2, 1996

798.00

42.50

March 1, 1996

798.00

42.50

April 3, 1996

798.00

42.50

May 3, 1996

798.00

42.50

June 3, 1996

798.00

42.50

August 2, 1996

798.00

42.50

September 3, 1996

798.00

42.50

October 1, 1996

798.00

42.50

November 1, 1996

798.00

42.50

December 3, 1996

798.00

42.50

January 3, 1997

821.00

43.80

February 3, 1997

821.00

43.80

March 3, 1997

821.00

43.80

April 3, 1997

821.00

43.80

May 2, 1997

821.00

43.80

June 3, 1997

821.00

43.80

July 3, 1997

821.00

43.80

August 1, 1997

821.00

43.80

September 3, 1997

821.00

43.80

October 3, 1997

821.00

43.80

November 3, 1997

821.00

43.80

December 3, 1997

821.00

43.80

EXHIBIT C - COURT REMAND FLAG

COURT REMAND FLAG

(OAO Completes Items 1-4)

1. Jurisdiction ____________________ Date of Court Remand Order ______________

2. Time Limit? (Circle one) YES NO

If YES, completed action required (specify) ________________________________

DUE DATE __ ­­__ / __ __/ __ __ __ __ Hearing Office Notified? YES NO

3. Delayed Case? (Circle one) YES NO

4. Does this jurisdiction* require a certified record even if the decision is fully favorable.

(Circle one) YES NO

*Idaho, Maine, New Hampshire, West Virginia, Wisconsin, E.D. North Carolina, E.D. Washington

IDENTIFICATION OF DECISION

(Decision Writer Completes Items 5, 6, and 7)

5. Claim type _________________________ (e.g., SSDC, DIWC, DIWW, etc.)

6. Nature of Decision(s)                                                 Route to:

     ___ Unfavorable Decision                                               ODAR, OAO

                                                                                                5107 Leesburg Pike

                                                                                                Falls Church, VA 22041-3255

      ___ Fully Favorable                                                 Same as non-court case

     ­­_ ___ Partially Favorable                                          Same as non-court case

7a. Is the decision fully favorable, AND the answer to item 4 above “YES”

                                      YES                              NO

7b. Is the decision partially favorable?

                                      YES                              NO

If either 7a or 7b is YES, the hearing office must enter the following remark on the route slip: “After effectuation, send the file (and hearing cassette, if any) to the Office of Appellate Operations, 5107 Leesburg Pike, Falls Church, VA 22041-3255

Call your Regional Office if you have any questions about routing a court remand case.

EXHIBIT D – “HALT EFFECTUATION” MEMORANDUM

Date     :

From    :        Director, Office of Acquiescence and Litigation Coordination,

                     Office of Disability Programs

Subject:        Potential Appeal (Case name, SSN) — ACTION

To                 :

This is to confirm a conversation in the above-referenced case. SSA may recommend an appeal of the court's decision. Please complete all development, but do not authorize or make any payments on this record until you receive further instructions from this office.

If you have any questions, please contact __________________________ , at

_______________________________.

EXHIBIT E – “