BASIC (05-11)

NL 00720.035 AGE Age

AGE006 DATE OF BIRTH HAS NOT BEEN ESTABLISHED FOR MEDICARE COVERAGE (Q23)

(Requested)

Caption: Information About Medicare

 (1)      (2) not qualify for  (3)  now because we have not received enough evidence

to prove that  (4)  reached age  (5)  . If you can furnish additional proof of  (6)  age, please contact any Social Security office promptly.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You

Choice 2: Mr. + Beneficiary's Last Name

Choice 3: Ms. + Beneficiary's Last Name

Fill-in (2) - Systems Generated

Choice 1: do

Choice 2: does

Fill-in (3) - Systems Generated

Choice 1: retirement benefits

Choice 2: disability

Choice 3: spouse's benefits

Choice 4: widow's benefits

Choice 5: widower's benefits

Choice 6: parent's benefits

Choice 7: disabled widow's benefits

Choice 8: disabled widower's benefits

Choice 9: Medicare

Fill-in (4) - Systems Generated

Choice 1: you have

Choice 2: he has

Choice 3: she has

Fill-in (5) - Systems Generated

Choice 1: 62

Choice 2: 50

Choice 3: 60

Choice 4: 65

Fill-in (6) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

AGER09 DEVELOPMENT OF FOREIGN BIRTH RECORD (C20)

(Requested)

Caption: The Basis For Our Decision

To pay benefits more quickly, we used  (1)  as  (2)  date of birth. This date is based on the documents  (3)  gave us. We are still waiting for a copy of the foreign birth record. If the foreign birth record does not agree with the date of birth we used, we may need to revise our decision about  (4)  date of birth. A different date of birth could affect your right to benefits or the amount of your payments. Also, if we paid you too much, you may have to pay us back. When we receive the foreign birth record, we will send you another letter to let you know if there will be a change in your payments.

Fill-in values:

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

Alleged date of birth in the format MM/DD/CCYY

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's name possessive

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


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900720035
NL 00720.035 - AGE Age - 12/01/2011
Batch run: 12/01/2011
Rev:12/01/2011