BASIC (10-15)

DI 28084.005 Identifying Information (Items 1 to 7)

A. Introduction to completing Items 1 to 7

Complete Items 1 through 7 using information from the latest determination or decision in file, unless recent information is available (such as a current copy of the Master Beneficiary Record (MBR) or Supplemental Security Record (SSR)). Follow these instructions to complete each item:

B. Item 1A - social security number

Enter the following:

  1. For the SSA-832, enter the social security number (SSN) of the recipient; and

  2. For the SSA-833, enter the SSN of the primary beneficiary. In childhood disability beneficiary (CDB) and disabled widow(er) beneficiary (DWB) cases, show the wage-earner's SSN. Enter the beneficiary identification code (BIC), shown under the BIC caption on the latest SSA-831-U3 (Disability Determination and Transmittal) in the claims folder (e.g., "A" for disabled Title II wage earner), to the right of the SSN.

    NOTE: Enter only "A" on the SSA-833 if the disabled wage earner's BIC shows "HA". Also, enter any numerical suffix following a designated BIC; e.g., "C1" (CDB), enter both "C" and "1".

C. Item 1B - type of claim or case

  1. For the SSA-832, enter an "X" to identify the Title XVI claim type using this chart:

    Type Definition

    DI

    disabled individual

    DS

    disabled spouse

    DC

    disabled child

    BI

    blind individual

    BS

    blind spouse

    BC

    blind child

  2. For the SSA-833, enter an "X" to identify the Title II claim type using this chart:

    Type Definition

    DIB

    disabled beneficiary (wage earner)

    FZ

    disability freeze (wage earner)

    DWB

    disabled widow/widower beneficiary

    CDB

    childhood disability beneficiary

    ESRD

    end-stage renal disease

    HIB

    health insurance benefit (Medicare benefit) (Also applicable for Medicare Qualified Government Employee (MQGE).)

D. Item 1C - other entitlement

Complete this item based on the following:

1. Concurrent entitlement

Enter an "X" in the block next to “Title II” or “Title XVI”, or both for concurrent (Title II and Title XVI) claims.

2. Dual Title II entitlement (SSA-833 only)

Enter the following information:

  • an "X" in the "Title II" block in dual Title II entitlement cases, e.g., DIB and DWB; and

  • the SSN, upon which the other Title II entitlement is based, in Item 24, Remarks; e.g., "DWB SSN - 000-00-0000."

NOTE: When processing a dual Title II entitlement determination, use a SSA-833 for each case; e.g. process a determination for DIB on a SSA-833 and process the DWB determination on a separate SSA-833.

E. Item 2A - name of payee (If any)

Enter the representative payee's name, if any, including the term “for”, “on behalf of” or “guardian of”.

NOTE: For completion of Item 29, if there is a representative payee, see DI 28084.055.

F. Item 2B - name of disabled or blind individual

Enter the first name, middle initial, and last name of the disabled or blind individual.

G. Item 2C – address for cases involving the Form SSA-833

Complete the following:

  • Enter the latest mailing address for the disabled or blind individual, or, if applicable, the representative payee;

  • Enter the disabled or blind individual's address in Item 24 (Remarks) if the representative payee's address is entered and the disabled or blind individual is legally competent;

  • Enter the zip code as part of the address;

  • Do not show the bank address if direct deposit is involved; and

  • Do not complete the address entry, enter "beneficiary deceased" when the beneficiary is deceased.

NOTE: The disability determination services (DDS) will obtain the mailing or payment address (ADDR) segment of a Master Beneficiary Record (MBR) query to verify that the address in file has not changed. The DDS must notify the address information to the field office (FO) for direct input to the MBR if the most current address is different from the one shown in the folder, see DI 81020.100 Electronic Assistance Requests (AR). Office of Disability Operations (ODO), Program Service Center (PSC) – Disability Processing Branch (DPB) and Office of Earnings International Operations (OEIO) will follow their direct input procedures.

H. Item 3 - wage earner’s name (SSA-833) or address (SSA-832)

1. For cases involving the Form SSA-833

Enter the name of the wage earner whose SSN appears in Item 1A if the case is a CDB or DWB.

2. For cases involving the Form SSA-832:

Enter the following information:

  • the latest mailing address for the recipient or the representative payee;

  • if the representative payee's address is entered in Item 3 and the recipient is legally competent, enter the recipient’s address in Item 24 (Remarks);

  • the zip code as part of the address;

  • do not show the bank address if direct deposit is involved; and

  • if the recipient is deceased do not complete the address entry, enter "recipient deceased".

NOTE: The DDS will obtain the ADDR segment of a Supplemental Security Income Selective Request (SSI2) query to verify that the address in file has not changed. The DDS will contact the FO using an AR with current address information, so the FO will update the SSR with the most recent address if necessary. ODO, PSC-DPB and OEIO will follow their direct input procedures.

I. Item 4 - date of birth

Enter a six-digit figure for the date of birth (01/03/59).

J. Item 5 - date disability began

1. SSA-831-U3 available

Enter the established onset date from Item 15A or Item 18B of the latest approved SSA-831-U3 in file or the date in the Date of Disability Onset (DDO) field of the Disability Insurance Benefit (DIB) section of the Abbreviated MBR Query (AACT) or Supplemental Security Income Data (SSID).

2. SSA-831-U3 not available

Query SSA's system to obtain the date disability began, and then enter the date in the DDO field of the DIB section of the AACT or SSID.

3. Title II or Title XVI case statutory blindness ends and disability begins

Enter the latest approved onset date from the SSA-831-U3 in cases where the disabled individual is no longer statutorily blind, but is still disabled.

4. Conversion cases

Enter "before 01/01/74" if disability continued or ceased under Title XVI or the State plan in conversion cases.

K. Item 6 – DO address

Enter a complete street or P.O. Box address and zip code for the field office (FO) having jurisdiction for the case.

L. Item 7 - DO and DDS code

Enter the following information:

  • the code of the FO having jurisdiction for the case under the DO CODE caption; and

  • the code of the DDS having jurisdiction under the DDS CODE caption.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0428084005
DI 28084.005 - Identifying Information (Items 1 to 7) - 10/27/2015
Batch run: 10/27/2015
Rev:10/27/2015