The carrier can submit a copy of the compensation decision, payment record, court
order, award letter, etc., which shows the payment data requested in lieu of or in
addition to completing the form SSA-1709.
Review the form and any attachments carefully to ensure accurate and necessary information
provided for computing offset.
EXAMPLE: Carriers will sometimes show incomplete information in Part II, Item 7.a., of the
form the initial WC rate, without showing the interim changes and carriers will sometimes
show money amounts on a “when paid” basis instead of showing the period the payment
was for. Carriers often incorrectly enter in Part II, Item 8.b.1. of the form the
total amount of medical expenses paid on a WC claim instead of entering only the amount
that was actually deducted from the lump sum payment. In this situation, verify that
the amount shown was the actual amount deducted from the lump sum and not paid by
See reminders for what is considered unacceptable proof in DI 52145.001E.
Reconcile any discrepancies by phone and document the call on a SSA-5002, Report of
Cancel any outstanding development control.
Process offset where applicable through MCS or ICF.
Fax the SSA-1709 to the electronic folder (EF) or Non-Disability Repository for Evidentiary
Documents (NDRed). (See GN 00301.322.)