TN 7 (10-16)

NL 00720.025 ADJ Adjustment

ADJ015 AERO UNDERPAYMENT IN EXCESS OF $30,000.00 (A03)

(Requested)

Caption: What We Will Pay

 (1)  may owe Federal income tax on this back payment. To find out, contact the Internal Revenue Service. They can answer  (2)  Federal income tax questions and provide  (3)  with additional information about computing such tax. If  (4)  any questions about the amount of back payment, or if  (5)  a yearly breakdown of this payment, contact us. Our telephone number and address are shown below.

Fill-in values:

Fill-in (1) - Systems Generated:

Choice 1: You

Choice 2: Beneficiary's Name

Fill-in (2) - Systems Generated:

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (3) - Systems Generated:

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (4) - Systems Generated:

Choice 1: you have

Choice 2: he has

Choice 3: she has

Fill-in (5) - Systems Generated:

Choice 1: you need

Choice 2: he needs

Choice 3: she needs

ADJ016 AUXILIARY'S BENEFIT CHANGED BY ONE RECOMPUTATION (A13)

(Requested)

Caption: Your Benefits

We changed  (1)  monthly benefit beginning  (2)  because we raised  (3)   (4)  benefit.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (2) - Requested As A Date In Format In Format Shown Below

Choice 1: Date benefit amount changed (MM/CCYY format)

Fill-in (3) - System Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (4) - Requested As A One Position Alpha Character

Choice 1: (A) husband's

Choice 2: (B) wife's

Choice 3: (C) former husband's

Choice 4: (D) former wife's

Choice 5: (E) father's

Choice 6: (F) mother's

ADJ017 PARTIAL ADJUSTMENT APPROVED COMPLETELY (A30)

(Requested)

Caption: Your Benefits

As  (1)  asked, we will withhold money from  (2)  checks to collect the  (3)  of  (4)  . We will withhold  (5)  each month for  (6)  months beginning  (7)   (8)  . After we collect the money, we will raise  (9)  benefits back to  (10)  regular monthly payment amount.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you

Choice 2: beneficiary's name

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (3) - Requested As A One Position Alpha Character

Choice 1: (A) overpayment

Choice 2: (B) penalty

Choice 3: (C) overpayment and penalty

Fill-in (4) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Amount of overpayment

Fill-in (5) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Amount of partial withholding

Fill-in (6) - Requested As A Number

Choice 1: Number of months the partial amount will be withheld (exclude fractions)

Fill-in (7) - Requested As A Date In Format MM/CCYY

MM/CCYY

Fill-in (8) - Requested As A One Position Alpha Character

Choice 1: (A) null

Choice 2: (B) and withhold the remaining amount due from

the first monthly check we pay after that

Fill-in (9) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (10) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

ADJ018 PARTIAL ADJUSTMENT APPROVED AT A RATE MORE THAN REQUESTED (A31)

(Requested)

Caption: Your Benefits

 (1)  asked us to use a lower rate when we withhold the money from  (2)  checks to collect  (3)   (4)  . We decided to withhold more than  (5)  requested, so that we can recover the overpayment in a shorter time.

We will withhold  (6)  per month for  (7)  months beginning  (8)   (9)  . After we have recovered  (10)  , we will raise  (11)  benefits back to  (12)  regular monthly amount.

Fill-in values:

Fill-in (1) Systems Generated

Choice 1: You

Choice 2: Beneficiary's name

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (4) - Requested As A One Position Alpha Character

Choice 1 (A): overpayment

Choice 2 (B): penalty

Choice 3 (C): overpayment and penalty

Fill-in (5) - System generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (6) - Requested As A Money Amount In Format $$$$$.¢¢

Amount of partial withholding

Fill-in (7) Requested As A Number

Number of months of partial withholding in effect

Fill-in (8) - Requested As A Date In Format Shown Below

MM/CCYY

Fill-in (9) - Requested As A One Position Alpha Character

Choice 1 (A): null

Choice 2 (B): and withhold the remaining amount due from the first monthly check we pay after that

Fill-in (10) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Amount of overpayment

Fill-in (11) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (12) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

ADJ019 FINAL ADJUSTMENT - FRACTION OF A MONTH (A32)

(Requested)

Caption: Your Benefits

We are withholding  (1)  from  (2)  benefits. This is the last money  (3)  owed because of  (4)  overpayment.

Fill-in values:

Fill-in (1) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Amount withheld

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

ADJ020 DUAL ENTITLEMENT AWARD - PRIMARY AND AUXILIARY/SURVIVOR BENEFITS AWARDED SIMULTANEOUSLY - CHECKS COMBINED (A39)

(Requested)

Caption: What We Will Pay

 (1)  benefit is  (2)  on  (3)  earnings record and  (4)  as a  (5)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Your

Choice 2: Beneficiary's Name possessive

Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Amount MBP after any SMI deductions and rounding from SAMBA

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (4) - Requested As A Money Amount In Format $$$$$.¢¢

Amount MBP this is LEMBA after rounding

Fill-in (5) - Requested As A One Position Alpha Character

Choice 1: (A) wife

Choice 2: (B) husband

Choice 3: (C) widow

Choice 4: (D) widower

Choice 5: (E) disabled widow

Choice 6: (F) disabled widower

Choice 7: (G) child

Choice 8: (H) mother

Choice 9: (I) father

ADJ021 DUAL ENTITLEMENT - AUXILIARY/SURVIVOR AWARD AFTER PRIMARY - SEPARATE PAYMENTS (A43)

(Requested)

Caption: What We Will Pay

This is in addition to the benefit on  (1)  own earnings record.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Choice 4: Beneficiary's Name possessive

ADJ022 BENEFITS RESUMED EFFECTIVE WITH DATE OF RECONSIDERATION OR WAIVER REQUEST - PROTEST DATED PRIOR TO EXPIRATION OF RECONSIDERATION (60 DAYS) (LAF D to LAF C ) (A45)

(Requested)

Caption: Your Benefits

We are paying  (1)  again beginning  (2)  because  (3)  asked us to review our overpayment decision. For now, we are still withholding the money which we already subtracted from  (4)  checks.

If we later find that our decision was correct, or that we cannot waive the overpayment,  (5)  will have to pay back the  (6)  which  (7)  . Someone from the local Social Security office will contact  (8)  to talk about the overpayment.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you

Choice 2: beneficiary's name

Fill-in (2) – Requested As A Date In Format Shown Below

Date payments resume (MM/CCYY format)

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (6) - Requested As A Money Amount In Format $$$$$.¢¢

Balance of overpayment

Fill-in (7) - Systems Generated

Choice 1: you owe

Choice 2: he owes

Choice 3: she owes

Fill-in (8) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

ADJ023 ENTITLEMENT CONVERSION — DIB TO RSI (A01)

(Requested)

Caption: Your Benefits

Because  (1)  reached  (2)   (3)  , we are changing  (4)  disability benefits to  (5)  benefits beginning  (6)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you have

Choice 2: Beneficiary's name has

Fill-in (2) - Requested As A One Position Alpha Character

Choice 1: (A) age 65

Choice 2: (B) full retirement age

Fill-in (3) - Systems Generated

Choice 1: null

Choice 2: 65 years

Choice 3: Full Retirement Age as determined from FRA

utility, displayed in format: 65 and 2 months

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (5) - Requested As A One Position Alpha Character

Choice 1: (A) retirement

Choice 2: (B) widow's

Choice 3: (C) widower's

Fill-in (6) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY of entitlement conversion

ADJ024 CHECK PARAGRAPH ADJUSTMENT NOTICE (GA2)(G16)

(System Generated)

Caption: What We Will Pay

  • The next check  (1)  will be for  (2)  , which is the money  (3)  due through  (4)  .

  •  (5)  next scheduled payment of  (6)  , which is for  (7)  , will be received on or about the  (8)  of  (9)  .

  • After that,  (10)  will receive  (11)  on or about the  (12)  of each month.

Fill-in values:

Fill-in (1)

Choice 1: you receive

Choice 2: Beneficiary Name receives

Fill-in (2)

PAMT (PMA)

Fill-in (3)

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (4)

COM minus 1 month in MM/CCYY format

Fill-in (5)

Choice 1: Your

Choice 2: His

Choice 3: Her

Fill-in (6)

CMA

Fill-in (7)

COM in MM/CCYY format

Fill-in (8) - Systems Generated

Choice 1: If PCI on the MBR = 1, generate third

Choice 2: If PCI on the MBR = 2, generate second Wednesday

Choice 3: If PCI on the MBR = 3, generate third Wednesday

Choice 4: If PCI on the MBR = 4, generate fourth Wednesday

Fill-in (9)

COM plus 1 month in MM/CCYY format

Fill-in (10)

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (11)

MBP

Fill-in (12)

Choice 1: If PCI on the MBR = 1, generate third

Choice 2: If PCI on the MBR = 2, generate second Wednesday

Choice 3: If PCI on the MBR = 3, generate third Wednesday

Choice 4: If PCI on the MBR = 4, generate fourth Wednesday

ADJ025 CHECK PARAGRAPH ADJUSTMENT NOTICE (GA1)(G16)

(System Generated)

Caption: What We Will Pay

  • The next check  (1)  will be for  (2)  , which is the money  (3)  due through  (4)  .

After that,  (5)  will receive  (6)  , on or about the  (7)  of each month.

Fill-in values:

Fill-in (1)

Choice 1: you receive

Choice 2: beneficiary's name receives

Fill-in (2)

CAMT (CMA)

Fill-in (3)

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (4)

COM in MM/CCYY format

Fill-in (5)

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (6)

MBP

Fill-in (7)

Choice 1: third

Choice 2: second Wednesday

Choice 3: third Wednesday

Choice 4: fourth Wednesday

ADJ027 A20 EXPLANATION (old G50/AB5)/(old A02/AA1)

(Requested)

Caption: Your Benefits

We  (1)  the monthly benefit amount beginning  (2)   (3)  .

Fill-in values:

Fill-in (1) - Requested As A One Position Alpha Character

Choice 1 (A): raised

Choice 2 (B): reduced

Choice 3 (C): changed

Fill-in (2) - Requested As A Date In Format Shown Below

MM/CCYY

Fill-in (3) - Requested As A One Position Alpha Character

Choice 1 (C): because we stopped paying another person on this record

Choice 2 (D): because we started paying another person on this record

Choice 3 (M): because of a change in the way we compute benefits when someone is entitled on more than one Social Security record

Choice 4 (O): because the cost of living increased

ADJ028 CHANGE IN BENEFIT RATE – RECOMP (A02) (AA6)

(Requested)

Caption: Your Benefits

We  (1)  the monthly benefit beginning  (2)  because we could pay  (3)  for more months after  (4)  reached  (5)   (6)  than we previously used when we figured  (7)  benefit.

Fill-in values:

Fill-in (1) - Requested As A One Position Alpha Character

Choice 1: (A) raised

Choice 2: (B) reduced

Choice 3: (C) changed

Fill-in (2) - Requested As A Date In Format MM/CCYY

MM/CCYY effective date of change

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: beneficiary's name

Fill-in (4) - Systems Generated Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (5) - Requested As A One Position Alpha Character

Choice 1: (A) age 65

Choice 2: (B) full retirement age

Fill-in (6) System Generated

Choice 1: Full Retirement Age as determined from FRA utility, displayed in format: 65 and 2 months

Choice 2: Null

Fill-in (7) - System Generated

Choice 1: your

Choice 2: his

Choice 3: her

ADJ029 CHANGE IN BENEFIT RATE DUE TO SPOUSE'S DEATH (A02) (AA7)

(Requested)

Caption: Your Benefits

We  (1)  the monthly benefit beginning  (2)  because of the death of  (3)  .

Fill-in values:

Fill-in (1) - Requested As A One Position Alpha Character

Choice 1 (A): raised

Choice 2 (B): reduced

Choice 3 (C): changed

Fill-in (2) – Requested As A Date In Format MM/CCYY

MM/CCYY effective date of change

Fill-in (3) - Requested As A Language

Name of deceased spouse

ADJ032 CHANGE IN BENEFIT RATE TO CREDIT MONTHS DECEASED SPOUSE NOT PAID (A02) (AA3)

(Requested)

Caption: Your Benefits

We  (1)  the monthly benefit beginning  (2)  to give  (3)  credit for months when we did not pay full benefits to  (4)  .

Fill-in values:

Fill-in (1) - Requested As A One Position Alpha Character

Choice 1: (A) raised

Choice 2: (B) reduced

Choice 3: (C) changed

Fill-in (2) - Requested As A Date In Format Shown Below

MM/CCYY effective date of change

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: beneficiary's name

Fill-in (4) - Requested As A Language

Name of deceased spouse

ADJ035 CHANGE IN BENEFIT RATE – RECEIPT OF OTHER PENSION (A02)(AA9)

(Requested)

Caption: Your Benefits

We  (1)  the monthly benefit beginning  (2)  because the pension  (3)  from  (4)  no longer  (5)   (6)  Social Security benefits.

Fill-in values:

Fill-in (1) - Requested As A One Position Alpha Character

Choice 1: (A) raised

Choice 2: (B) reduced

Choice 3: (C) changed

Fill-in (2) - Requested As A Date In Format Shown Below

MM/CCYY effective date of change

Fill-in (3) - Systems Generated

Choice 1: Beneficiary's name gets

Choice 2: you get

Fill-in (4) - Requested As A Language

Name of the agency paying pension

Fill-in (5) - Requested As A One Position Alpha Character

Choice 1 (A): reduces

Choice 2 (B): affects the way we figure

Fill-in (6) - Systems Generated

Choice 1: his

Choice 2: her

Choice 2: your

ADJ037 CHANGE IN BENEFIT RATE – FRA (A02) (AB2)

(Requested)

Caption: Your Benefits

We  (1)  the monthly benefit beginning  (2)  because we could pay  (3)  at the full rate for more months before  (4)   (5)  than we previously used when we figured  (6)  benefit.

Fill-in values:

Fill-in (1) - Requested As A One Position Alpha Character

Choice 1: (A) raised

Choice 2: (B) reduced

Choice 3: (C) changed

Fill-in (2) - Requested As A Date In Format Shown Below

MM/CCYY effective date of change

Fill-in (3) - Systems Generated

Choice 1: Beneficiary's Name

Choice 2: you

Fill-in (4) - Requested As A One Position Alpha Character

Choice 1: (A) age 65

Choice 2: (B) full retirement age

Fill-in (5) - Systems Generated

Choice 1: Full Retirement Age as determined from FRA utility, displayed in format: 65 and 2 months

Choice 2: Null

Fill-in (6) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

ADJ038 NAME: EXPLANATION – CHILD IN CARE RECEIVING BENEFITS (G50) (AB6)

(Requested)

Caption: Your Benefits

We raised the monthly benefit amount beginning  (1)  to give  (2)  credit for months before  (3)  reached  (4)  when  (5)  caring for a child who was receiving benefits.

Fill-in values:

Fill-in (1) - Requested As A Date In Format Shown Below

MM/CCYY

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: beneficiary's name

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (4) - Systems Generated

Choice 1: age 65

Choice 2: full retirement age

Fill-in (5) - Systems Generated

Choice 1: you were

Choice 2: he was

Choice 3: she was

ADJ039 EXPLANATION – RAISED SURVIVOR BENEFITS DUE TO WORK AND EARNINGS (G50) (AB7)

(Requested)

Caption: Your Benefits

We raised the monthly benefit amount beginning  (1)  to give  (2)  credit for months when  (3)  was entitled to full benefits but did not receive them because of work and earnings.

Fill-in values:

Fill-in (1 - Requested As A Date In Format Shown Below

MM/CCYY

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's name

Fill-in (3) - Requested As A Language

Choice 1: Name of deceased spouse

ADJ041 NAME: EXPLANATION – EARNED LESS THAN ESTIMATE (G50) (AB9)

(Requested)

Caption: Your Benefits

We raised the monthly benefit amount beginning  (1)  because  (2)  earned less money after  (3)  reached  (4)  than  (5)  originally estimated.

Fill-in values:

Fill-in (1 - Requested As A Date In Format Shown Below

MM/CCYY

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: beneficiary's name

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (4) - Requested As A One Position Alpha Character

Choice 1: (A) age 65

Choice 2: (B) full retirement age

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

ADJ043 EXPLANATION – CREDIT FOR DECEASED SPOUSE'S EARNINGS (old G50/AC1)/ (old A02/AA5)

(Requested)

Caption: Your Benefits

We raised the monthly benefit amount beginning  (1)  to give  (2)  credit for months when  (3)  reached  (4)  but did not receive benefits because of work and earnings.

Fill-in values:

Fill-in (1) - Requested As A Date In Format Shown Below

MM/CCYY

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's name

Fill-in (3) - Requested As A Language

Name of deceased spouse

Fill-in (4) - Systems Generated

Choice 1: age 65

Choice 2: full retirement age

Fill-in (5) - Systems Generated

Choice 1: full retirement age as determined from FRA utility, displayed in format 65 and 2 months

Choice 2: null

ADJ044 EXPLANATION – CREDIT FOR NOT RECEIVING BENEFITS (olsG50/AC2)/(old A02/AA8)

(Requested)

Caption: Your Benefits

We raised the monthly benefit amount beginning  (1)  to give  (2)  credit for months when  (3)  reached  (4)   (5)  and did not receive a retirement benefit.

Fill-in values:

Fill-in (1) - Requested As A Date In Format Shown Below

MM/CCYY

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's name

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (4) - Systems Generated

Choice 1: age 65

Choice 2: full retirement age

Fill-in (5) - Systems Generated

Choice 1: full retirement age as determined from FRA utility, displayed in format 65 and 2 months

Choice 2: null

ADJ045 EXPLANATION – ARF ADJUSTMENT (G50) (AC3)

(Requested)

Caption: Your Benefits

We raised the monthly benefit amount beginning  (1)  to give  (2)  credit for benefits, which we did not pay at the full rate before  (3)  reached  (4)   (5)  . This was because of  (6)  work and earnings.

Fill-in values:

Fill-in (1) - Requested As A Date In Format Shown Below

MM/CCYY

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's name

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (4) - Systems Generated

Choice 1: age 65

Choice 2: full retirement age

Fill-in (5) - Systems Generated

Choice 1: FRA years + FRA months

Choice 2: null

Fill-in (6) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

ADJ046 AWARD CHECK PARAGRAPH DIRECT DEPOSIT (G92) (G03)

(System Generated)

Caption: What We Will Pay

  •  (1)  first check is for  (2)  .

  • This is the money  (3)  due through  (4)  .

  • After that,  (5)  will receive  (6)  on or about the  (7)  of each month  (8)  monthly payments will go to the financial institution  (9)  selected.

Fill-in values:

Fill-in (1)

Choice 1: Your

Choice 2: His

Choice 3: Her

Choice 4: Beneficiary name possessive

Fill-in (2)

PMA

Fill-in (3)

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (4)

COM in MM/CCYY format

Fill-in (5)

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (6)

MBP

Fill-in (7)

Choice 1: third

Choice 2: second Wednesday

Choice 3: third Wednesday

Choice 4: fourth Wednesday

Fill-in (8)

Choice 1: Your

Choice 2: His

Choice 3: Her

Fill-in (9)

Choice 1: you

ADJ047 AWARD CHECK PARAGRAPH DIRECT DEPOSIT (G93) (G03)

(System Generated)

Caption: What We Will Pay

  •  (1)  first payment is for  (2)  .

  • This is the money  (3)  due through  (4)  .

  •  (5)  next scheduled payment of  (6)  , which is for  (7)  , will be received on or about the  (8)  of  (9)  .

  • After the first payment,  (10)  will receive  (11)  on or about the  (12)  of each month.

  •  (13)  monthly payments will go to the financial institution  (14)  selected.

Fill-in values:

Fill-in (1)

Choice 1: Your

Choice 2: His

Choice 3: Her

Choice 4: Beneficiary name possessive

Fill-in (2)

PMA

Fill-in (3)

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (4)

COM minus 1 month in MM/CCYY format

Fill-in (5)

Choice 1: Your

Choice 2: His

Choice 3: Her

Fill-in (6)

CMA

Fill-in (7)

COM in MM/CCYY format

Fill-in (8)

Choice 1: third

Choice 2: second Wednesday

Choice 3: third Wednesday

Choice 4: fourth Wednesday

Fill-in (9)

COM plus 1 month in MM/CCYY format

Fill-in (10)

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (11)

MBP

Fill-in (12)

Choice 1: third

Choice 2: second Wednesday

Choice 3: third Wednesday

Choice 4: fourth Wednesday

Fill-in (13)

Choice 1: Your

Choice 2: His

Choice 3: Her

Fill-in (14)

Choice 1: you

ADJ048 A18 NOTICE - CHECK PARAGRAPH AC5 (G56)

(System Generated)

Caption: What We Will Pay

 (1)  will soon receive a check for payment of  (2)  because we owed money to  (3)  . This payment is in addition to any monthly payments (4) may receive.

Fill-in values:

Fill-in (1)

Choice 1: You

Choice 2: Beneficiary's name

Fill-in (2)

Amount

Fill-in (3) Requested by the Tech

Name of deceased beneficiary

Fill-in (4) Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

ADJ049 A18 NOTICE–CHECK PARAGRAPH FOR MEDICARE REFUND AC6(G56)

(System Generated)

Caption: What We Will Pay

 (1)  will soon receive a check for  (2)  because  (3)  due a refund of  (4)  Medicare prescription drug plan costs.

Fill-in values:

Fill-in (1)

Choice 1: You

Choice 2: Beneficiary's Name

Fill-in (2)

Amount

Fill-in (3)

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (4)

Choice 1: your

Choice 2: his

Choice 3: her

ADJ050 EXPLANATION (G50)

(Requested)

Caption: Your Benefits

We  (1)  the monthly benefit amount beginning  (2)  to give  (3)  credit for additional earnings.

Fill-in values:

Fill-in (1) - Requested As A One Position Alpha Character

Choice 1: (A) raised

Choice 2: (B) reduced

Fill-in (2) - Requested As A Date In Format Shown Below

MM/CCYY

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's name

ADJ051 EXPLANATION (G50)

(Requested)

Caption: Your Benefits

We  (1)  the monthly benefit amount beginning  (2)  to give  (3)  credit for a period of disability.

Fill-in values:

Fill-in (1) - Requested As A One Position Alpha Character

Choice 1: (A) raised

Choice 2: (B) reduced

Fill-in (2) - Requested As A Date In Format Shown Below

MM/CCYY

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's name

ADJ052 EXPLANATION (G50)

(Requested)

Caption: Your Benefits

We  (1)  the monthly benefit amount beginning  (2)  to give  (3)  credit for months when we did not pay at the full rate before  (4)  reached age 62. This was because of  (5)  work and earnings.

Fill-in values:

Fill-in (1) - Requested As A One Position Alpha Character

Choice 1: (A) raised

Choice 2: (B) reduced

Fill-in (2) - Requested As A Date In Format Shown Below

MM/CCYY

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's name

Fill-in (4) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (5) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

ADJ053 EXPLANATION (G50)

(Requested)

Caption: Your Benefits

We  (1)  the monthly benefit amount beginning  (2)  to correct  (3)  benefit amount.

Fill-in values:

Fill-in (1) - Requested As A One Position Alpha Character

Choice 1: (A) raised

Choice 2: (B) reduced

Fill-in (2) - Requested As A Date In Format Shown Below

MM/CCYY

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's name possessive

ADJ054 AWARD CHECK PARAGRAPH GENERAL G89 (G02)

(System Generated)

Caption: What We Will Pay

  •  (1)  first check is for  (2)  .

  • This is the money  (3)  due through  (4)  .

  • After that,  (5)  will receive  (6)  on or about the  (7)  of each month.

Fill-in values:

Fill-in (1)

Choice 1: Your

Choice 2: Beneficiary's name possessive

Fill-in (2)

PMA in format $$$$$.¢¢

Fill-in (3)

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (4)

COM in MM/CCYY format

Fill-in (5)

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (6)

MBP in format $$$$$.¢¢

Fill-in (7)

Choice 1: If PCI on the MBR = 1, generate third

Choice 2: If PCI on the MBR = 2, generate second Wednesday

Choice 3: If PCI on the MBR = 3, generate third Wednesday

Choice 4: If PCI on the MBR = 4, generate fourth Wednesday

ADJ055 AWARD CHECK PARAGRAPH GENERAL G90 (G02)

(System Generated)

Caption: What We Will Pay

  •  (1)  first check is for  (2)  .

  • This is the money  (3)  due through  (4)  .

  •  (5)  next scheduled payment of  (6)  which is for  (7)  , will be received on or about the  (8)  of  (9)  .

  • After that,  (10)  will receive  (11)  on or about the  (12)  of each month.

Fill-in values:

Fill-in (1)

Choice 1: Your

Choice 2: Beneficiary's Name possessive

Fill-in (2)

PMA in format $$$$$.¢¢

Fill-in (3)

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (4)

COM minus 1 month in MM/CCYY format

Fill-in (5)

Choice 1: Your

Choice 2: His

Choice 3: Her

Fill-in (6)

CMA in format $$$$$.¢¢

Fill-in (7)

COM in MM/CCYY format

Fill-in (8)

Choice 1: If PCI on the MBR = 1, generate third

Choice 2: If PCI on the MBR = 2, generate Second Wednesday

Choice 3: If PCI on the MBR = 3, generate third Wednesday

Choice 4: If PCI on the MBR = 4, generate fourth Wednesday

Fill-in (9)

COM plus 1 month in MM/CCYY format

Fill-in (10)

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (11)

MBP in format $$$$$.¢¢

Fill-in (12)

Choice 1: If PCI on the MBR = 1, generate third

Choice 2: If PCI on the MBR = 2, generate second Wednesday

Choice 3: If PCI on the MBR = 3, generate third Wednesday

Choice 4: If PCI on the MBR = 4, generate fourth Wednesday

ADJ056 EXPLANATION (AA1)

(Requested)

Caption: Your Benefits

We  (1)  the monthly benefit beginning  (2)  because we changed the month when  (3)  first due benefits.

Fill-in values:

Fill-in (1) - Requested As A One Position Alpha Character

Choice 1: (A) raised

Choice 2: (B) reduced

Choice 3: (C) changed

Fill-in (2) - Requested As A Date In Format Shown Below

MM/CCYY

Fill-in (3) - Systems Generated

Choice 1: you were

Choice 2: Beneficiary's name was

ADJ057 EXPLANATION (AA1)

(Requested)

Caption: Your Benefits

We  (1)  the monthly benefit beginning  (2)  , because we could pay  (3)  at the full rate for more months before age 62 than we previously used when we figured  (4)  benefits

Fill-in values:

Fill-in (1) - Requested As A One Position Alpha Character

Choice 1: (A) raised

Choice 2: (B) reduced

Choice 3: (C) changed

Fill-in (2) - Requested As A Date In Format Shown Below

MM/CCYY

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's name

Fill-in (4)

Choice 1: your

Choice 2: his

Choice 3: her

ADJ058 CHECK PARAGRAPH G56. A18 NOTICE (AC4)

(System Generated)

Caption: What We Will Pay

   (1)  will soon receive a check for  (2)  because  (3)  .

Fill-in values:

Fill-in (1)

Choice 1: You

Choice 2: Beneficiary name

Fill-in (2)

Amount in format $$$$$.¢¢

Fill-in (3)

Choice 1: (A) of an additional lump-sum payment

Choice 2: (D) of a rate increase

Choice 3: (E) a former payee returned a check

Choice 4: (H) we are refunding excess premiums for medical insurance

Choice 5: (I) of a returned benefit check

Choice 6: (L) we were withholding money to pay an attorney fee, and no fee was charged

Choice 7: (O) a former payee returned checks

ADJ059 CHECK PARAGRAPH G56. A18 NOTICE (AC4)

(System Generated)

Caption: What We Will Pay

 (1)  will soon receive a check for  (2)  because we had withheld money from  (3)  benefits.

Fill-in values:

Fill-in (1)

Choice 1: You

Choice 2: Beneficiary name

Fill-in (2)

Amount

Fill-in (3)

Choice 1: your

Choice 2: his

Choice 3: her

ADJ060 CHECK PARAGRAPH G56. A18 NOTICE (AC4)

(System Generated)

Caption: What We Will Pay

 (1)  will soon receive a check for  (2)  because  (3)  due money in addition to  (4)  regular monthly benefit check.

Fill-in values:

Fill-in (1)

Choice 1: You

Choice 2: Beneficiary name

Fill-in (2)

Amount

Fill-in (3)

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (4)

Choice 1: your

Choice 2: his

Choice 3: her

ADJ061 CHECK PARAGRAPH G56. A18 NOTICE (AC4)

(System Generated)

Caption: What We Will Pay

 (1)  will soon receive a check for  (2)  because we withheld money from  (3)  benefits due to  (4)  work or earnings.

Fill-in values:

Fill-in (1)

Choice 1: You

Choice 2: Beneficiary name

Fill-in (2)

Amount in format $$$$$.¢¢

Fill-in (3)

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (4)

Choice 1: your

Choice 2: his

Choice 3: her

ADJ062 CHECK PARAGRAPH G56. A18 NOTICE (AC4)

(System Generated)

Caption: What We Will Pay

 (1)  will soon receive a check for  (2)  because  (3)  eligible for provisional benefits.

Fill-in values:

Fill-in (1)

Choice 1: You

Choice 2: Beneficiary name

Fill-in (2)

Amount in format $$$$$.¢¢

Fill-in (3)

Choice 1: you are

Choice 2: he is

Choice 3: she is

ADJ063 CHECK PARAGRAPH G56. A18 NOTICE (AC4)

(System Generated)

Caption: What We Will Pay

 (1)  will soon receive a check for  (2)  because  (3)  sent us too much money when  (4)  refunded  (5)  overpayment.

Fill-in values:

Fill-in (1)

Choice 1: You

Choice 2: Beneficiary name

Fill-in (2)

Amount in format $$$$$.¢¢

Fill-in (3)

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (4)

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (5)

Choice 1: your

Choice 2: his

Choice 3: her

ADJ064 CHECK PARAGRAPH G56. A18 NOTICE (AC4)

(System Generated)

Caption: What We Will Pay

 (1)  will soon receive a check for  (2)  because we are sending  (3)  money which we did not have to use to pay an attorney fee.

Fill-in values:

Fill-in (1)

Choice 1: You

Choice 2: Beneficiary name

Fill-in (2)

Amount in format $$$$$.¢¢

Fill-in (3)

Choice 1: your

Choice 2: his

Choice 3: her


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900720025
NL 00720.025 - ADJ Adjustment - 06/07/2017
Batch run: 06/07/2017
Rev:06/07/2017