TN 6 (12-05)

NL 00715.025 Basic Framework for All AJS-1 Notices

A. Description of Basic Framework for all AJS-1 Notices

Organization

UTI#

Language

Heading – first line & second line

UTI SSAH01

Social Security Administration

Retirement, Survivors and Disability Insurance

Heading – third line

UTI SSAH07

Notice of Change in Benefits

PSC Name & Address

UTI SSAH40 – SSAH47

SSAH40

Northeastern Program Service Center

1 1 Jamaica Center Plaza

2 Jamaica, New York 11432-3898

SSAH41

Mid-Atlantic Program Service Center

1 300 Spring Garden Street

2 Philadelphia, Pennsylvania

19123-2992

SSAH42

Southeastern Program Service Center

1 1200 Rev. Abraham Woods, Jr. Blvd

2 Birmingham, Alabama 35285-0001

SSAH43

Great Lakes Program Service Center

1 600 West Madison Street

2 Chicago, Illinois 60661-2474

SSAH44

Western Program Service Center

1 P.O. Box 2000

2 Richmond, California 94802-1791

SSAH45

Mid-America Program Service Center

1 601 East Twelfth Street

2 Kansas City, Missouri 64106-2859

SSAH46

Office of Central Operations

1 1500 Woodlawn Drive

2 Baltimore, Maryland 21241-1500

SSAH47

Office of Central Operations

1 P.O. Box 17769

2 Baltimore, Maryland 21235-7769 U.S.A.

FILL-IN

(1) CERTIFIED MAIL/TELEPHONE CONTACT/NULL

(2) 999-999-9999/NULL

Date/Claim Numbers

UTI SSAH84

SSAH84

Date: (1)

Claim Number(s): (2)

FILL-IN

(1) (MMDDYYCC) Format: October 26, 1998

(2) (999-99-9999XXXX

999-99-9999XXXX)

Format:123-45-6789 HA

123-45-6788 C1

PNA data (& POSTNET Barcode)

UTI SSAH30

Payee Name and Address

Finalist Nine-Digit Zip code

Finalist 12-Digit Barcode Representation

XXXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXX, XX XXXXX-XXXX

A*999999999999*

FILL-IN

(1) “CERTIFIED MAIL”/”TELEPHONE CONTACT/NULL

(2) 999-999-9999/NULL

(See Function 3.2, Determine Processing Center Name and Address and Function 3.3, Determine Blind Notices for generation criteria.)

Claim Number/PIC & Page Numbering

UTI BLS014

BLS014

(1) _

FILL-IN

(1) (999-99-9999 XXXX)

Commissioner’s Signature

UTI SSAS01 (replaces #3939 in the AJS-1 wordbank)

SSAS01

Signature Block

(Digitized Signature)

Jo Anne B. Barnhart

Commissioner

of Social Security

Caption used with certain payment UTIs

UTI PAYC01

PAYC01

What We Will Pay And When

Caption used with recon/appeal UTI (ALS020)

UTI ALSC04

ALSC04

If You Disagree With The Decision

Caption used with referral /UTIs

UTI REFC01

REFC01

If You Have Any Questions