Take the name and address from Form SSA-831-U5 shown in the “Name and Address of Claimant” block or Form SSA-3428-U2, Determination of Disallowance Coding Sheet, “Name and Address Information” field in Block 2. If the disability examiner or claims authorizer in ODO requests
this notice use Form SSA-L837B.
This notice requires three fill-ins:
date given when disability began
The necessary fill-ins for this notice should be shown on Form SSA-831-U5 or Form
SSA-3428-U2. If the fill-ins are not shown, return the claim to the individual who
initiated the action.
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.