TN 49 (08-08)
DI 11010.205 Completing the Paper SSA-831
The following section contains FO procedure for completing the paper SSA-831 (Disability Determination and Transmittal) in disability claims that are Electronic Disability Collect System (EDCS) exclusions or limitations (Certified Electronic Folder (CEF) Exclusions and Limitations - DI 81010.030).
NOTE: Complete Substantial Gainful Activity (SGA) denials in EDCS unless the case is an exclusion. See Using Form Attestation for Work Activity Reports (DI 81010.120) and Processing Field Office (FO) Determinations (DI 81010.140C) for instructions on processing SGA denials electronically.
A. How to complete items 1-19
1. Item 1 - destination
Check the ODO block if the current claim is being transmitted to ODO. If the claim is being transmitted to the PSC, line through ODO and enter PSC/DPB. Check the “OIO” block if the claimant's address is outside the 50 States, District of Columbia, Puerto Rico, American Samoa, Guam, the Northern Mariana Islands and U.S. Virgin Islands. Check the “DDS” block in all other cases.
2. Item 2 - DDS code
For cases to be forwarded to a Disability Determination Services (DDS), show the appropriate 3 digit DDS code listed in the Detailed Office/Organization Resource System (DOORS).
3. Item 3 - filing date
Show the actual month, day, and year of filing of the current application. The only exception to this rule is when an earlier filing date (i.e., protective filing) is established based on a written or telephone request for benefits, see Protective Filing (GN 00204.010), in which case show the earlier date. If there are two or more current applications, show the earliest filing date.
4. Item 4 - SSN
Enter the Social Security Number (SSN) of the individual on whose E/R the benefits are being claimed. This is the primary SSN even though the individual has multiple SSNs and may have used another SSN at the field office (FO) interview or when he/she filed a prior claim. In CDB and DWB (including Medicare only) claims, also show the claim symbol e.g., HC1, W, E, and D. In End Stage Renal Disease (ESRD) claims, enter the spouse's or parent's SSN if the ESRD claimant is receiving benefits on that SSN. In all other ESRD cases, use the claimant's SSN.
5. Item 5 - name and address of claimant
Enter the name and mailing address of the claimant. If a proper applicant, see Proper Applicant - GN 00204.003, has filed on behalf of the claimant, enter the applicant's name for the appropriate legend followed by the word “for”, and then the claimant's name, and applicant's mailing address. Enter names exactly as shown on the claim. If two or more proper applicants have filed on behalf of the claimant the name and address entries for the applicant should be for whichever of the applicants is the preferred payee. See Payee Preference Lists - GN 00502.105.
In situations involving a disability application filed after the claimant's death, show the applicant's name followed by “On behalf of (claimant's name) Dec'd.” If the SSA-831 is for the deceased parent of a child filing on a grandparent's ER, enter the name only of the disabled parent.
6. Item 6 - WE's name
Number Holder’s (NH's) Name, complete for CDB and DWB claims involving a DIB NH. This item is not completed in DIB Cases.
7. Item 7 - type claim (Title II)
Check the appropriate block as follows:
Disability Insurance Benefits
Disabled Widow(er)'s Benefits
Childhood Disability Benefits (RSI NH)
Childhood Disability Benefits (DIB NH)
End Stage Renal Disease - Claimant receiving RSI benefits on spouse's or parent's SSN
End Stage Renal Disease - Claimant receiving auxiliary benefits on the SSN of a spouse or parent entitled to DIB
End Stage Renal Disease - Claimant receiving monthly benefits on own SSN or not receiving monthly benefits
Disability determination for parent-child filing on earnings record of grandparent (RSI NH)
Disability determination for parent-child filing on earnings record of grandparent (DIB NH)
Medicare for Qualified Government Employees
8. Item 8- type claim (Title XVI)
Check the appropriate block.
9. Item 9- Date of Birth (DOB)
Show the established month, day, and year of birth (e.g., 3/17/49). If the date of birth has not been established, use the DOB by which the claimant is the oldest.
10. Item 10- prior action
Check the “PD” block when the last determination for the same type of benefit was a denial. Check the “PT” block when the last determination for the same type of benefit was a termination of entitlement. Include the prior disability file, if in the FO or required as shown in Impairment-Related Work Expenses (IRWE) Paid 12/01/80, and Later (DI 11010.180) and complete information on a SSA-3367 (Disability Report-Field Office), Item 7.
11. Item 11 - remarks
Document the following:
For instructions on documenting prisoner cases, see DI 10105.094.
Complete items 11A and 11B (the blocks do not need to be checked) with code 01 in 11A and an impairment number from Field Office (FO) Procedures for Processing Presumptive Disability (PD) AND Presumptive Blindness (PB) Cases DI 11055.240D.1.a. in 11B.
12. Item 12 - FO address/FO code
Enter the City, State, ZIP code and FO code, as well as the local address (street number and name or P.O. Box), in all cases.
13. Item 13 - FO representative
The FO employee who transmits the case should enter his/her name and title in this block.
14. Item 14 - date
Enter the date the file is transmitted to the DDS, ODO, DPB or OIO.
15. Item 16 - diagnosis
Enter “None established” for Substantial Gainful Activity (SGA) denials.
16. Item 19A - claimant not disabled through date of current determination
Check this block when the insured status or prescribed period requirement continues to be met through the date of the current determination.
17. Item 19B - claimant not disabled through (date)
Check this block when the prescribed period ended or the insured status requirement was last met prior to the date of the current determination. Enter the date the insured status or prescribed period requirement is last met.
18. Item 19C - before age 22
Complete this item for CDB cases.
B. How to complete item 20 – vocational background
1. Item 20 - vocational background
Complete this item in DIB, DWB, DWB Medicare Only, Freeze and CDB cases. Show both the claimant's occupation and the industry. Enter the 2-digit occupation code from the list below which most closely approximates the determined occupation. Follow the code with a dash and then enter the approximate 2-digit industry code from the list below most closely approximating the determined industry. If a CDB has never had an occupation, enter “NONE.”
Occupation Codes (Item 20 of SSA-831)
PROFESSIONAL TECHNICAL, AND MANAGERIAL OCCUPATIONS
Occupation in architecture, engineering, and surveying
Occupation in mathematics and physical sciences
Occupation in life science
Occupation in medicine and health
Occupation in education
Occupation in museum, library, and archival sciences
Occupation in law and jurisprudence
Occupation in religion and theology
Occupation in writing
Occupation in art
Occupation in entertainment and recreation
Occupation in administrative specializations
Managers and officials
Other professional, technical, and managerial occupations
CLERICAL AND SALES OCCUPATIONS
Stenography, typing, filing, and related occupations
Computing and account-recording occupations
Production and stock clerks and related occupations
Information and message distribution occupations
Sales occupation, services
Sales occupation, consumable commodities
Sales occupation, commodities other than consumable
Other clerical occupation
Other sales occupation
Domestic service occupations
Food and beverage preparation and service occupation
Lodging and related service occupation
Barbering, cosmetology, and related service occupation
Amusement and recreation service occupation
Other personal service occupation (e.g., hostesses, stewards, hospital attendants, practical nurses, etc.)
Apparel and furnishings service occupation
Protective service occupation
Office service occupation
Other non-personal service occupation
AGRICULTURAL, FISHERY, FORESTRY, AND RELATED OCCUPATIONS
Plant farming occupation
Animal farming occupation
Fishery and related occupation
Hunting, trapping, and related occupation
Other agricultural, fishery, forestry and related occupation
Occupation in processing of metal
Ore refining and foundry occupation
Occupation in processing of food, tobacco, and related products
Occupation in processing of paper and related materials
Occupation in processing of petroleum, coal, natural and manufactured gas, and related products
Occupation in processing of chemicals, plastics, synthetics, rubber, paint, and related products
Occupation in processing of wood and wood products
Occupation in processing of stone, clay, glass, and related products
Occupation in processing of leather, textiles, and related products
Other processing occupation
MACHINE TRADES OCCUPATIONS
Metal machining occupation
Mechanics and machinery repairers
Paper working occupation
Wood machining occupation
Occupation in machining stone, clay, glass, and related materials;
Other machine trades occupation
Occupation in fabrication, assembly, and repair of metal products
Occupation in fabrication and repair of scientific, medical, photographic, optical horological, and related products
Occupation in assembly and repair of electrical equipment
Occupation in fabrication and repair of products made from assorted materials
Painting, decorating, or related occupation
Occupation in fabrication and repair of plastics, synthetics, rubber and related products
Occupation in fabrication and repair of wood products
Occupation in fabrication and repair of sand, stone, clay, and glass products
Occupation in fabrication and repair of textile, leather, and related products
Other bench work occupation
STRUCTURAL WORK OCCUPATIONS
Occupation in metal fabricating
Welder, cutter, or related occupation
Electrical assembling, installing, and repairing occupation
Painting, plastering, waterproofing, cementing, or related occupation
Excavating, grading, paving or related occupation
Other structural work occupation
Motor freight occupation
Packaging and materials handling occupation
Occupation in extraction of minerals
Occupation in production and distribution of utilities (e.g., energy, water, sewage)
Amusement, recreation, motion picture, radio and television occupations not included in the preceding
Industry Codes (Item 20 of SSA-831)
AGRICULTURE, FORESTRY, FISHING, HUNTING AND TRAPPING
Agriculture production crops
Agriculture production livestock
Fishing, hunting, and trapping
MINING AND COAL AND GAS EXTRACTION (INCLUDING URANIUM)
Bituminous coal and lignite mining
Oil and gas extraction
Mining and quarrying of nonmetallic minerals, except fuels
Building construction – general contractors and operative builders
Construction other than building construction – general contractors
Construction - special trade contractors (e.g., plumbing, heating, electrical, carpentry, etc.)
Food and kindred products
Textile mill products
Apparel and other finished products made from fabrics and similar materials
Lumber and wood products, except furniture
Furniture and fixtures
Paper and allied products
Printing, publishing, and allied industries
Chemicals and allied products
Petroleum refining and related industries
Rubber and miscellaneous plastics products
Leather and leather products
Stone, clay, glass and concrete products
Primary metal industries
Fabricated metal products, except machinery and transportation equipment
Machinery, except electrical
Electrical and electronic machinery, equipment, and supplies
Measuring, analyzing, and controlling instruments, photographic, medical, and optical goods; watches and clocks
Other manufacturing industries
Local and suburban transit and interurban highway passenger transportation
Motor freight transportation and warehousing
U.S. postal service
Transportation by air
Pipe lines, except natural gas
Electric, gas, and sanitary services
Wholesale trade – durable goods
Wholesale trade – nondurable goods
Building materials, hardware, garden supply, and mobile home dealers
General merchandise stores
Automotive dealers and gasoline service stations
Apparel and accessory stores
Furniture, home furnishings and equipment stores
Eating and drinking places
Credit agencies other than banks
Security and commodity brokers, dealers, exchanges, and services
Insurance agents, brokers, and service
Combination of real estate, insurance, loans, law offices
Holding and other investment offices
Hotels, rooming houses, camps, and other lodging places
Automotive repair, services, and garages
Miscellaneous repair services
Amusement and recreation services, except motion pictures
Museums, art galleries, botanical and zoological gardens
Executive, legislative, and general government, except finance
Justice, public order, and safety
Public finance, taxation, and monetary policy
Administration of human resources programs
Administration of environmental quality and housing programs
Administration of economic programs
National security and international affairs
Show in the “Occ. Yrs.” block the number of years that the claimant worked in the principal occupation, if determined, or, if not determined, in the longest full-time occupation. When such information is not reflected on the SSA-3368 (Disability Report - Adult) and/or SSA-3369 (Work History Report), it may appear elsewhere in the file. Where there are broken periods of employment in that occupation, determine the total number of years the claimant was employed or available for employment in the shown occupation. If the number of occupational years is unknown, enter “unk.”
In the “Ed. Yrs.” block, enter the highest grade of school completed by the individual, including any part-time and night courses. Use “12th grade” to indicate completion of high school, “13th grade” for one year of college, etc. Also, enter the type of school and number of years completed in specialized schools, such as nursing school, accounting school or ungraded vocational school. If the number of years of education is unknown, enter “unk.”
C. How to complete item 22 – reg basis code
For DIB/DWB claims use the following chart:
DIB/DWB claim—insured status or prescribed period last met on or after date of current decision.
DIB/DWB claim—prescribed period ended or insured status last met prior to date of current decision.
For CDB claims, use the following guide:
If the individual is engaging in SGA:
Is the SGA determination prior to age 22? If yes, use code N1. If no go to step b.
Does the CDB have any prior CDB entitlement? If no, use N2. If yes, go to step c.
Was the prior CDB entitlement terminated due to SGA? If yes, use N1. If no, go to step d.
Is the SGA determination being made within the 84-month re-entitlement period? If yes use N1. If no, use N2. (Assumption that the prior entitlement was terminated due to medical recovery.)
D. How to complete items 26-29
1. Item 26 - list No.
See Disability-Related List Codes (Active) - DI 33530.005.
2. Item 27 - rationale
See Background - DI 26516.001.
3. Item 29 - LTR. /PAR. No.
Complete this item in accordance with Preparing Notices in Disability Claims - DI 11010.345.
E. How to complete items 37-38
1. Item 37 - SSA representative
The claims representative signs his or her name.
2. Item 38 - date
Enter the date the SSA-831 is signed.
F. FO remarks
When preparing a case to be sent to DDS, keep in mind the following situations requiring specific remarks:
Always enter the telephone number (including the area code) where the claimant can be reached. If the claimant gives an address that is general delivery, a hospital or an institution, enter the claimant's home address or the address of a friend or relative who would know the whereabouts of the claimant.
If the claimant's mailing address is in one State, and he/she resides in another State, enter “Resides in (name of State).” Show the county if the DDS indicates a need for this information. The case is sent to the DDS servicing the claimant's residence address.
Enter alleged onset date.
Enter the reason a DDS determination is needed.
The “Remarks” portion is used to alert the DDS or of special situations. The following are some of the principal notations:
1. DIB transmittal to DDS delayed for E/R
If a DIB claim is transmitted to the DDS prior to FO receipt of the ER, enter “DLI (date).” Also, if the DIB claimant alleges a visual impairment and is fully insured only, enter the remark “Fully insured only.”
NOTE: Do not forward initial materials for a disability determination if there is any doubt as to whether the claimant meets a non-disability requirement (e.g., insured status or prescribed period requirement). In cases delayed pending resolution of a non-disability requirement, do not forward the application, E/R or other non-disability material to the DDS. Send only the material pertinent to the disability determination when the issues are resolved.
2. Concurrent DWB-DIB
If concurrent DWB-DIB claims are being processed, cross refer as follows; enter on the SSA-831 (Disability Determination and Transmittal) “Also filing as disabled widow(er) on (SSN)”, and enter on the DWB SSA-831 “Also filing for DIB on (SSN).”
3. DWB claimant is DIB beneficiary
If a DWB claimant is already receiving DIB, enter “Widow(er) entitled to DIB on (SSN).”
4. Concurrent Title II-Title XVI
If either of the following situations is applicable, enter the appropriate remark: “Title XVI initial (or reconsideration) filed (date), pending in DDS.” or “Prior Title XVI denial (or cessation) (date).”
5. CDB/DIB - same SSN
In cases involving a disabled claimant and a disabled child auxiliary living in different jurisdictions, cross-refer each SSA-831 by entering “(CDB or DIB) application for (name of claimant or disabled child) forwarded to (DDS, ODO, DPB, DRS, or OIO) on (date).”
6. DIB/CDB - different SSNs
When a disabled child has disability insured status on his or her own SSN and has filed disability application in addition to the auxiliary claim, enter on the SSA-831 associated with the DIB claim, “See (parent's name) (parent's SSN) for CDB claim.”
7. No waiting period case
If the claim is a no waiting period case, enter “no waiting period.” (See When No Waiting Period Is Required DI 10105.075 for the definition of a no waiting period case.)
8. Visual impairment alleged
Enter “Alleges visual impairment” when a visual impairment is alleged.
9. Claimant does not want to pursue claim
Enter “Claimant does not want to pursue claim” if the claimant does not want to complete development (Claimant Cannot be Contacted. Whereabouts Unknown or Claimant Does not Wish to Pursue Title II Claim - DI 11010.045). In an ODO case, enter “No medical evidence for reasons beyond claimant's control” if the claimant is unable to proceed with the claim.
10. DIB after death
In cases involving a disability application filed after the claimant's death, show the date of death; i.e., “Date of death (date).”
11. Claimant also filed RIB or Survivor claim
If the claimant filed a RIB or non-disability survivor's claim, enter “Application for RIB or survivors benefits.”
12. Foreign language notice required
If a foreign language notice is required, enter “foreign language notice required,” using the appropriate language in place of “foreign language.”
13. Braille notice requested
See details in Procedure for the Braille Special Notice Option for the Blind or Visually Impaired (NL 01001.120).
14. Homeless - no permanent address
Enter “Homeless - no permanent address” when the claim is for a homeless individual.
15. Possible application of Res Judicata
When a subsequent Title II disability claim is being transmitted in accordance with Initial Title II Technical Denials and Claims Not Requiring a Disability Determination - DI 11010.075, enter: “Prior claim attached. Review for application of res judicata." If the prior claim could not be located, enter: “Prior claim not located - Substantive determination necessary.”
16. Applying FO adoption
When a subsequent Title II or Title XVI disability claim is being sent to DDS per FO Adoption Decision -DI 11011.005, enter “FO unable to adopt prior decision.”
17. MSSICS limitation
Indicate the reason for the limitation and claim type.
18. Amyotrophic Lateral Sclerosis (ALS) — Medicare waiting period waived
Public Law 106-1554 amended section 226 of the Social Security Act to waive the 24 month waiting period for Medicare coverage for disabled individuals medically determined to have ALS. The date of Medicare entitlement is the date of entitlement to disability insurance benefits or 07/01, whichever is later. This applies to new and current claims.
G. How to complete item 28 on the paper SSA-831
When the DDS makes a final determination resulting in an allowance on a Title II DIB or Freeze claim, the FO must complete certain blocks and dates in item 28 if a paper SSA-831 exists. The DDS always checks blocks A and C on DIB and Freeze allowances.
The FO should complete the SSA-831 as follows:
enter the first date (month, day, year) the claimant is disabled (item 15A) and meets insured status requirements in block C.
check block D, except for closed period of disability cases.
enters “claimant died (date)” in item 34 if the claimant died after completing the waiting period,
check block E and enter the last day of the second month after the month disability ceased (item 15B), and
NOTE: If there is a closed period of disability, DDS completes items 15A and 15B.
check block E and enter the last day of the month and year before the month of attainment of FRA if the claimant is full retirement age (FRA) at the time of the allowance.