TN 53 (05-09)

NL 00703.905 Disallowance Miscellaneous Fill-in Letter

                

Document Processing System (DPS) Identifier: (Initial Claims Folder)

                     

Exhibit - DPS Disallowance – Misc. Reason

        

Disallowance – Title II Misc Reason

     

Social Security Administration

Retirement, Survivors and Disability Insurance

Notice of Disapproved Claim

[F1]

Claim Number: [F1]

[F2]

[F1]

[F1]

[F2]

Optional (SSAH74)

     

Dear [F1]

We have considered your application for Social Security benefits.

Mandatory Choice 1 of 3 (DSL008)

The rules in Section 211 of the Social Security Protection Act of 2004 apply on this record because the worker is not a citizen or national of the United States. Under this law, [F1] must meet one of the following requirements in order for anyone to get benefits on this record:

  • At some time have been assigned a Social Security number (SSN) and issued an SSN card that is valid for work purposes; /or/

  • Have been admitted to the U.S. at any time as a business visitor (immigration status “B-l”) or noncitizen crewman (immigration status “D-l” of “D-2”).

According to our records, neither of these requirements is met. Therefore, [F2] not entitled to benefits.

Let us know right away if [F3] authorized to work in the United States, admitted to the U.S. as business visitor or noncitizen crewman, or granted U.S. citizenship.

If you are in the U.S., contact the Department of Homeland Security, U.S. Citizenship and Immigration Services at the toll-free number, 1-800-375-5283, for more information about immigration and U.S. citizenship. If you are outside the United States and need more information, contact the closest U.S. Embassy or Consulate.

Mandatory Choice 2 of 3 (MAR033)

You cannot get benefits because your marriage does not meet the requirements under Federal law for payment of Social Security [F1] benefits.

Mandatory Choice 3 of 3 (AAA019)

[F1]

Page 1

Other Social Security Benefits

You do not qualify for any other Social Security benefit based on the application you filed. In the future, if you think you may be entitled to benefits, you will need to apply again.

You will receive another letter if you filed for Supplemental Security Income payments.

If You Disagree With the Decision

If you disagree with this decision, you have the right to appeal. A person who did not make the first decision will decide your case. We will review those parts of the decision which you disagree with and will look at any new facts you have. We may also review those parts which you believe are correct and may make them unfavorable or less favorable to you.

  • You have 60 days to ask for an appeal.

  • The 60 days start the day after you receive this letter. We assume you got this letter 5 days after the date on it unless you show us that you did not get it within the 5-day period.

  • You will have to have a good reason for waiting more than 60 days to ask for an appeal.

  • To appeal, you must fill out a form called "Request for Reconsideration." The form number is SSA-561. To get this form, contact one of our offices. We can help you fill out the form

New Application

You have the right to file a new application at any time, but filing a new application is not the same thing as appealing this decision. If you disagree with this decision and you file a new application instead of appealing:

  • you might lose some benefits, or not qualify for any benefits, and

  • we could deny the new application using this decision, if the facts and issues are the same.

So, if you disagree with this decision, you should file an appeal within 60 days.

If You Want Help With Your Appeal

You can have a friend, representative or someone else help you. There are groups that can help you find a representative or give you free legal services if you qualify. There also are representatives who do not charge unless you win your appeal. Your Social Security office has a list of groups that can help you with your appeal.

If you get someone to help you, you should let us know. If you hire someone, we must approve the fee before he or she can collect it.

Page 2

If You Have Any Questions

Mandatory Choice 1 of 3 (REF038)

For general information about Social Security we invite you to visit our website at www.socialsecurity.gov on the Internet. For general questions and specific questions about [F1] case, you may call us toll-free at 1-800-772-1213, or call your local Social Security office at [F2] and ask for [F3]. We can answer most questions over the phone. If you are deaf or hard of hearing, you may call our TTY/TDD number [F4]. If you do call or visit an office, please have this letter with you. It will help us answer your questions.

Mandatory Choice 2 of 3 (REF061)

We invite you to visit our web site at www.socialsecurity.gov on the Internet to find general information about Social Security. If you have any specific questions, you may call us toll-free at 1-800-772-1213, or call your local office at [F1]. We can answer most questions over the phone. If you are deaf or hard of hearing, you may call our TTY number, 1-800-325-0778. You can also write or visit any Social Security office. The office that serves your area is located at:

[F2]

If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

Mandatory Choice 3 of 3 (REF002)

We invite you to visit our website at www.socialsecurity.gov on the Internet to find general information about Social Security. If you have any specific questions, you should contact any Social Security office or the nearest United States Embassy or consulate.

Or, if you live in the Philippines, you may contact the Veterans Administration Regional Office, Social Security Division, 1131 Roxas Boulevard, Manila.

You may also write the Social Security Administration, P.O. Box 17769, Baltimore, Maryland, 21235-7769, USA. Please be sure to include your claim number if you do write. However, if you visit an office, please take this letter. It will help the people there answer your questions. Medicare information is available on the Internet at www.medicare.gov.

[Fl]

[F2]

[F3]

Page 3

[F1]

      

      

      

Page 4

    

 View PDF Version

A. Exhibit letter language for AURORA E3905

We have considered your application for Social Security benefits.

           

(1)

                  

Other Social Security Benefits

3901E

         

If You Disagree With the Decision

3900B

                     

New Application

3900A

             

If You Want Help With Your Appeal1

3100E

                 

If You Have Any Questions

3901C - Domestic

3901D - Foreign

                 

Enclosure:

SSA Pub. No. 05-10058

B. Notice Instructions for Users

Follow the instructions below.

  • Send in situations where none of the other disallowance notices applies. Use 3901E, 3900B and 3900A in all cases. Use 3901F for same-sex marriage. Refer to NL 00703.901 for 3901E text. For 3900B and 3900A text, refer to NL 00703.900 and for 3100E text, NL 00703.100.

  • For 3901C and 3901D text and fill-ins refer to NL 00703.005E.

          

Fill-ins:

  1. Type any other needed paragraph in this space, i.e., the reason for the disallowance.

Same-Sex Marriage Disallowance UTI

Use 3901F (2 MAR033) if disallowance is due to a same-sex marriage.

You can not get benefits because your marriage does not meet the requirements under Federal law for payment of Social Security (fill-in) benefits.

           

  1. spouses’s

  2. widow’s

  3. widower’s

  4. divorced spouse’s

  5. surviving divorced spouse’s

C. Typing instructions for Preparing the Notice

Use Form SSA-L2000-C2 (Universal Notice). Refer to Form SSA-3428-U2 (Determination of Disallowance Coding Sheet) “Name and Address Information” field in block 2 for completing the name and address. Because the fill-ins may vary according to the different situations, follow the requester's typing instructions carefully. If the disability examiner indicates Form SSA-L829-U2, Request for Medical Information from Military Facilities or Records Center, or Form SSA-3428-U2 or SSA-832-U3, Cessation or Continuation of Disability/Blindless Determination and Transmittal – Title XVI, and word processor notice E3905 is not shown, return to the claims authorizer/claims technical expert for required fill-ins for E3905.

D. Exhibit of Spanish letter

This letter is available in DPS.

     

Disallowance Miscellaneous Fill-in Letter

  1. Exhibit Letter Language

    Hemos considerado su solicitud para beneficios de Seguro Social.

    (1)

    Otros beneficios de Seguro Social

    3901E

    Si no esta de acuerdo con la decision

    3900B

    Solicitud nueva

    3 900A

    Si quiere ayuda con su apelacion

    3100E

    Si tiene alguna pregunta

    3901C - Domestic 390ID - Foreign1

  2. Notice Instructions for Users

    Follow the instructions below.

    • Send in situations where none of the other disallowance notices applies. Use 3901E, 3900B and 3900A in all cases. Refer to NL 00703.901 for 3901E text. Refer to NL 00703.900 for 3900B and 3900A text and NL 00703.100 for 3100E text.

    • Refer to NL 00703.005E for 3901C and 3901D text and fill-ins.

    Fill-ins:

    Type any other needed paragraph in this space, i.e., the reason for the disallowance.

    If reason for disallowance is due to same-sex marriage, request:

    UTI #E3901F Su matrimonio no cumple con los requisitos, segun la ley federal, para beneficios de (1) del Seguro Social.

    1. conyuge,

    2. viuda

    3. viudo

    4. conyuge divorciado

    5. conyuge divorciado sobreviviente

  3. Typing Instructions for Preparing the Notice

    Use Form SSA-L2000-C2 (Universal Notice). Refer to Form SSA-3428-U2, Determination of Disallowance Coding Sheet, “Name and Address Information” field in block 2 for completing the name and address. Because the fill-ins may vary according to the different situations, follow the requester's typing instruct