TN 1 (02-11)

DI 23515.010 Disability Determination Services (DDS) SSA-831-U5 and Notice Completion for Non-Citizen Cases

A. How to Complete the SSA-831-U5

Complete the SSA-831-U5 (Disability Determination and Transmittal) for any Title XVI claim with the following exceptions:

Item Action

15 See DI 23515.005 for onset date instruction

18B Same date as item 15

27 Be alert that change in onset is determined from the alleged onset of disability, not the filing date, as in regular Title XVI claims.

B. How to complete rationales and notices

1. Rationale preparation

Use the same requirements for technical rationales, as for regular Title XVI claims.

2. Notice Preparation

  • Non-citizen

Do not release a personalized disability notice in unfavorable determinations.

Prepare an attachment for use by the field office (FO) as part of an overall non-citizen denial notice; and

Place the attachment in the file.

The FO releases an overall notice of determination, including information about the disability determination.

  • Aged non-citizen age 65 and older

The disability determination is only one of the criteria for eligibility. Do not release a personalized disability notice in unfavorable determinations.

Prepare an attachment to be used by the field office as part of an overall non-citizen denial notice; and

Place the attachment in the file.

The FO releases an overall notice of determination including information about the disability determination.

3. Preparing the attachment

  • Non-citizen

The attachment has the individual's name in the upper left hand corner, the Social Security Number in the upper right hand corner, and the title “INFORMATION ABOUT THE DISABILITY DECISION” centered below those entries (see DI 23515.010 for an example).

The attachment contains the following headings that are included in personalized disability notices: “The Decision on Your Case,” “About the Decision,” “The Disability Rules,” and “Information About Substantial Work. “

  • Aged non-citizen age 65 and older

The attachment has the individual's name in the upper left hand corner, the SSN in the upper right hand corner, and the title centered below those entries (see DI 23515.010 for an example).

The attachment contains the following headings that are included in personalized disability notices: “The Decision on Your Case,” “About the Decision,” “The Disability Rules,” and “Information About Substantial Work.” also contains information normally contained under those headings.

For a reconsideration affirmation, use the standard Form SSA L1130-U2, SSI Notice of Recon-Disability.

NOTE: For a reconsideration affirmation, use the standard Form SSA L1130-U2, SSI Notice of Recon-Disability.

C. Exhibits for non-citizen cases

Exhibit 1 (model language for DDS letter to DHS)

DDS Letterhead

Department of Homeland Security District Office
(Address)

We are writing to obtain medical evidence on behalf of (claimant's name and address) who has applied for payments based on disability or blindness under the Supplemental Security Income provision of Title XVI of the Social Security Act. This agency is responsible for determining, on behalf of the Commissioner of the Social Security Administration, whether the claimant is disabled or blind and whether the onset of disability or blindness occurred before or after admission to the United States for permanent residence.

To make such a determination, we need a copy of Form OF-157 (Medical Examination of Visa Applicants) and/or any other medical reports contained in your file. The claimant's authorization is enclosed.

 

The claimant was admitted to the United States for permanent residence on _______ (date), at ________ (place of entry) and was going to live at ­­­­­­­­­­­­_________ (address). His or her non-citizen registration number is       .

 

Your prompt response will help assure a speedy decision on this claim. If you have any questions, please call this agency collect. Thank you for your cooperation.

Sincerely yours,

Chief Medical Consultant

Enclosure

Exhibit 2 – Disability Determination Notice – Non Citizens Age 65 and Older [

(Claimant Name)(SSN)

INFORMATION ABOUT THE DISABILITY DECISION

The Decision on Your Case

{For Personalized Disability Language instructions, see DI 26530.000 ff.}

About the Decision

Doctors and other trained staff looked at your case and made this decision. They work for the State but used our rules.

Please remember that there are many disability programs, both government and private, that use different rules. A person may be receiving benefits under another program and still not be entitled under our rules. This may be true in your case.

The Disability Rules

You must meet certain rules to qualify for SSI payments based on disability. Your health problems must:

keep you from doing any kind of substantial work (described below), and

last, or be expected to last, for at least 12 months in a row, or

be expected to result in death

You must meet certain rules to qualify for SSI payments based on blindness.

Your eyesight must be no better than 20/200 in the better eye with the use of a corrective lens, or

Your visual fields must be restricted to 20 degrees or less.

You can qualify for SSI benefits due to blindness even if you can do substantial work.

Information About Substantial Work

Generally, substantial work is physical or mental work you are paid to do. Work can be substantial even if it is part-time. To decide if your work is substantial, we consider the nature of the job duties, the skills and experience you need to perform the job, and your earnings.

Usually, we find that your work is substantial, if your gross earnings average over $1000 per month after we deduct allowable amounts. Your work may be different from your work before your health problems began. It may not be as hard to do and your pay may be less. However, we may still find that your work is substantial under our rules.

If you are self-employed, we consider the kind and value of your work, including your part in the management of the business, as well as your income, to decide if your work is substantial.

Exhibit 3 (map of DHS regional and district areas)

G-DI_23515.020C

 View PDF Version

Exhibit 4 (DHS regional offices)

DHS Region

Office Address

Eastern Region (BUR)

Burlington, Vermont 05401
Federal Building
Elmwood Avenue

Northern Region (STP)

Twin Cities, Minnesota 55111
Bishop Henry Whipple
Federal Building
Fort Snelling

Southern Region (DLS)

Dallas, Texas 75270
Skyline Center
Building C
311 North Stemmons Freeway

Western Region (SPD)

San Pedro, California 90731
Terminal Island

Exhibit 5 (DHS servicing offices by state)

State

DHS DO Number

DHS Regional Office

Alabama

26

Southern

Alaska

32

Northern

Arizona

18

Western

Arkansas

28

Southern

California

13, 16, 39

Western

Colorado

19

Northern

Connecticut

23

Eastern

Delaware

4

Eastern

D.C.

25

Eastern

Florida

6

Southern

Georgia

26

Southern

Hawaii

17

Western

Idaho

30

Northern

Illinois

9

Northern

Indiana

9

Northern

Iowa

29

Northern

Kansas

11

Northern

Kentucky

28

Southern

Louisiana

28

Southern

Maine

22

Eastern

Maryland

5

Eastern

Massachusetts

2

Eastern

Michigan

8

Northern

Minnesota

10

Northern

Mississippi

28

Southern

Missouri

11

Northern

Montana

30

Northern

Nebraska

29

Northern

Nevada

13

Western

New Hampshire

2

Eastern

New Jersey

21

Eastern

New Mexico

15

Southern

New York

3,7

Eastern

North Carolina

26

Southern

North Dakota

10

Northern

Ohio

24

Northern

Oklahoma

20

Southern

Oregon

31

Northern

Pennsylvania

4

Eastern

Puerto Rico

27

Eastern

Rhode Island

2

Eastern

South Carolina

26

Southern

South Dakota

10

Northern

Tennessee

28

Southern

Texas

14, 15, 20, 38

Southern

Utah

19

Northern

Vermont

1

Eastern

Virginia

25

Eastern

Washington

12

Northern

West Virginia

4

Eastern

Wisconsin

9

Northern

Wyoming

19

Northern

Wisconsin

9

Northern

Wyoming

19

Northern

Exhibit 6 (DHS district offices)

DHS District Offices

 

DO Abbrev.

Office

 2
(BOS)

Boston, Massachusetts 02203
John Fitzgerald Kennedy
Federal Building
Government Center

 3
(NYC)

New York, New York 10278
26 Federal Plaza

 4
(PHI)

Philadelphia, Pennsylvania
19106
Room 1321 U.S. Courthouse
Independence Mall West
601 Market Street

 5
(BAL)

Baltimore, Maryland 21201
E.A. Garmatz Federal Bldg.
101 West Lombard Street

 6
(MIA)

Miami, Florida 33138
7880 Biscayne Blvd.

 7
(BUF)

Buffalo, New York 14202
68 Court Street

 8
(DET)

Detroit, Michigan 48207
Federal Bldg.
333 Elliot St.

 9
(CHI)

Chicago, Illinois 60604
Dirksen Federal Office Bldg.
219 South Dearborn St.

 10
(SPM)

St. Paul, Minnesota 55101
927 New Post Office Bldg.
180 N. Kellogg Blvd.

 11
(KAN)

Kansas City, Missouri 64106
Suite 1100, 324 E. Eleventh St.

 12
(SEA)

Seattle, Washington 98134
815 Airport Way, South

 13
(SFR)

San Francisco, California 94111
Appraisers Bldg.
630 Sansome Street

 14
(SNA)

San Antonio, Texas 78206
Suite A301
U.S. Federal Bldg.
727 East Durango

 15
(ELP)

El Paso, Texas 79984
343 U.S. Courthouse
P.O. Box 9398

 16
(LOS)

Los Angeles, California 90012
300 North Los Angeles Street

31

 (POO)

Portland, Oregon
Federal Office Building
511 N.W. Broadway

 32
(ANC)

Anchorage, Alaska 99513
New Federal Building
701 C St. RM. D-251
Lock Box 16

 17
(HHW)

Honolulu, Hawaii 96809
P.O. Box 451
595 Ala Moana Blvd.

 18
(PHO)

Phoenix Arizona 85025
Federal Bldg.
230 North First Avenue

 19
(DEN)

Denver, Colorado 80202
1787 Federal Bldg.
1961 Stout St.

 20
(DAL)

Dallas, Texas 75242
Room 6A21, Federal Bldg.
1100 Commerce St.

 21
(NEW)

Newark, New Jerse