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Item 3 (Filing Date)
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Enter the application filing date established by the administrative law judge (ALJ)
decision.
See DI 42010.025 for the filing date to use and action to take when the ALJ reopens a prior determination
or decision.
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Item 4 (SSN)
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Enter the NH's Social Security number, and the claimant’s Beneficiary Identification
Code (BIC) if processing a Childhood Disability Benefits (CDB) or Disabled Widows
Benefits (DWB) decision.
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Item 5 (Name and Address of Claimant)
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Enter the name and address as shown on the hearing decision.
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Item 6 (NH's Name)
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Complete for CDB and DWB claims only.
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Item 7 (Type Claim)
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Check the appropriate boxes, extract from the prior SSA-831.
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Item 9 (Date of Birth)
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Extract from the file.
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Item 11 (Remarks)
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Enter “Concurrent title II/title XVI” in concurrent cases; otherwise leave blank.
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Item 12 (District Branch Office Address)
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Enter the information for the field office that services the claimant’s address of
record.
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Item 15 (Claimant Disabled)
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Check box 15A and enter the exact date of onset specified by the ALJ. When a closed
period of disability is established, check box 15B and enter the date of disability
cessation specified in the ALJ’s decision.
When an ALJ awards both closed and open periods of disability in a single decision,
prepare two SSA-831s, one for each period of disability.
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Item 16A and 16B (Primary and Secondary Diagnosis)
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In Item 16A, enter the primary diagnosis. Enter the 2-digit body system code and the
4-digit diagnosis code in the blocks labeled “Body Sys.” and “Code,” respectively.
See DI 26510.015F and DI 26510.015G for complete lists of body system and diagnosis codes.
If the hearing decision indicates a secondary diagnosis, complete Item 16B with the
name and 4-digit diagnosis code. If there is no secondary diagnosis, write “None”
and use the code 0000.
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Item 17 (Diary)
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Enter the Diary Type, Date (MM/YY) and Reason code, following the instructions in
DI 26510.020. See DI 26525.020 for determining when to code a medical improvement expected (MIE) diary.
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Item 18 (Case of Blindness as Defined in Section 1614(a)(2)/(216(i))
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See DI 26010.025 for completing this section when statutory blindness is established.
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Item 20 (Vocational Background)
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Enter the code from the prior SSA-831, if applicable.
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Item 24 (MOB Code)
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Enter the code from the prior SSA-831, if applicable.
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Item 25 (Revised Det.)
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Place a check in this box.
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Item 25A (Adjudicative Level)
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Check box D under “ALJ Hearing.” If the ALJ issued the decision on remand, also check
the boxes for Appeals Council and U.S. District Court as needed.
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Item 26 (List No)
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Include up to six list codes. See instructions in DI 26510.070 and DI 33530.005.
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Item 28
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Check boxes A (Period of Disability) and C (Estab. Beg.) for all favorable title II
Disability Insurance Benefit (DIB) decisions. For the establishment date, use the
later of:
-
•
The disability onset date in Item 15A; or
-
•
The date the number holder first attained insured status.
If the hearing decision states that the number holder remains disabled, check box
D.
If the title II portion of a hearing decision establishes an onset date prior to the
date insured status is first met, place an asterisk (*) after the date next to box
C and add the following remark in Item 34: “*, date insured status is first met.”
Process the award using the insured status date as the onset date and route the case
to a Reconsideration Disability Examiner (REDE). Instruct the REDE to prepare a protest
memorandum requesting an amended decision with a corrected established onset date.
If the disability has ended, check box E and enter the last day of the period of disability.
The period of disability ends with the last day of whichever of the following months
is earliest:
-
•
The second month after the month in which disability ceases (see DI 10105.010); or
-
•
The month before the month the worker attains full retirement age (FRA); or
-
•
The month in which the worker dies.
If the hearing decision establishes both a closed period of disability and a second,
continuing period, the first period of disability (and benefit entitlement) will terminate
on the last day of the second month following cessation of disability. A second period
can begin no earlier than the first day after termination. Prepare separate Forms
SSA-831-U-5 for each period of disability.
The ALJ decides that a claimant’s disability ceases June 15, 2020, and the corresponding
period of disability ends August 31, 2020. In the same decision, the ALJ also determines
that the claimant is entitled to a second period of disability based on an onset of
August 8, 2020. In this situation, Block C should show the second period of disability
as beginning on September 1, 2020. Annotate Item 34 with the following remark: “Dates
in Items 15 and 28 differ—new period of disability established following cessation.”
If an ALJ sets a subsequent disability onset during a prior period of entitlement,
see DI 42010.025B.4.
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Item 34 (Remarks)
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Enter the following remarks:
“This reverses the determination dated [date of reconsideration determination affirming
initial disallowance].”
“Decision of Administrative Law Judge [name of ALJ] on [date of Decision].”
If the claimant has an appointed representative, enter “Representative involved.”
Include the primary representative’s name and address.
Indicate any other pertinent issues regarding capability, earnings discrepancies,
workers’ compensation, no waiting period, multiple SSNs, etc.
This reverses the determination dated 12/06/18. Decision of ALJ John Jones on 02/08/20,
Representation Dan Daniels, PO Box 123, Minneapolis, MN 60888. Capability unresolved.
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Item 36 (Revised Det. Codes)
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Enter a two-character alphanumeric code indicating whether the prior decision was
an allowance (A) or a denial (D); and whether a prior application was reopened (9)
or not reopened (5).
If the prior decision was a denial, and no prior application was reopened, enter D-5.
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Item 37 (SSA Representative/SSA Code)
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The SSA adjudicator or reviewer should sign in Item 37 and identify their component
by entering the appropriate Processing Center (PC) number (1-8) in the “SSA CODE”
block.
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Item 38 (Date)
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Enter the date of adjudication in MM/DD/YY format.
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