Take the name and address from Form SSA-831-U5 or Form SSA-3428-U2, Determination
of Disallowance Coding Sheet, “Name and Address Information” field in Block 2.
There are no fill-ins required for this notice.
NOTE: Personalized disability notice procedures implemented July 1, 1981, require that
Forms SSA-4268-U6/C6 be attached to unfavorable disability form notices. In addition
to preparing this form notice according to instructions, the typist must:
Type the personalized and technical rationales on the Form SSA-4268-U6 or SSA-4268-C6.
Prepare appropriate rider (or include paragraphs on form notice if there is room).
Assemble form notice, personalized rationale and the rider stapled together in that
order, with envelope for mailing.