TN 4 (08-03)

GN 03501.046 Sample Transmittal Flag

EXHIBIT 1

Transmittal Flag

Transmittal Flag

AR Readjudication Request

TO:     DDS/OHA address and routing code

FROM:    FO address and routing code

LEVEL OF LAST DETERMINATION (CHECK ONE BLOCK)

[ ] INITIAL  [ ]  RECONSIDERATION   [ ] OHA LEVEL

CLAIM NUMBER

NAME


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0203501046
GN 03501.046 - Sample Transmittal Flag - 08/11/2003
Batch run: 01/27/2009
Rev:08/11/2003