TN 4 (08-12)

NL 00720.060 BEN Benefit Information

BEN031 NOTICE TO N/H WHEN DISABILITY ESTABLISHED IN DIB/RIB CLAIMS NO RECAL PROCESSED (J87)

(Requested)

Caption: Your Benefits

Since  (1)  now entitled to a higher monthly disability benefit, we are stopping  (2)  retirement benefits.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Surname is

Choice 2: you are

Fill-in (2) - Systems Generated

Choice 1: her

Choice 2: his

Choice 3: your

BEN032 ADJUSTMENT IN RETROACTIVE BENEFITS IN FIRST/NEXT CHECK (M09)

(Requested)

Caption: Your Benefits

In  (1)   (2)  payment,  (3)  will receive the difference between the benefits already paid and those now due.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Surname possessive

Choice 2: Beneficiary Full name possessive

Choice 3: your

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

Choice 1: (A) first

Choice 2: (B) next

Fill-in (3) - Systems Generated

Choice 1: she

Choice 2: he

Choice 3: you

BEN050 SPECIAL PAYMENT PROVISION FOR CHILDHOOD DISABILITY BENEFICIARY, WIDOW, WIDOWER, MOTHER OR PARENT WHO IS TERMINATED FOR MARRIAGE OR RE MARRIAGE (T09)

(Requested)

Caption: Your Benefits

We might still be able to pay  (1)  if  (2)  married a person who is receiving Social Security benefits. Please get in touch with us if this is true.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary's Name

Choice 2: You

Fill-in (2) - Systems Generated

Choice 1: he

Choice 2: she

Choice 3: you

BEN051 BENEFICIARY ENTITLED ON MORE THAN ONE ACCOUNT BENEFITS COMBINED INTO ONE CHECK (B16)

(Requested)

Caption: Your Benefits

We will send  (1)  both benefits in one check each month under  (2)  own claim number.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you

Choice 2: her

Choice 3: him

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

BEN052 BENEFICIARY ENTITLED TO BENEFITS ON MORE THAN ONE ACCOUNT EACH BENEFIT PAID SEPARATELY (B18)

(Requested)

Caption: Your Benefits

We will send  (1)  separate checks each month under each claim number.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you

Choice 2: her

Choice 3: him

BEN053 DUAL ENTITLEMENT AWARD OF PRIMARY BENEFITS WHEN BENEFICIARY PREVIOUSLY AWARDED AS AN AUXILIARY (B15)

CAUTION: Use BEN053 only on the primary (BIC A) record. If BEN053 is requested on the auxiliary record, the systems generated fill-ins cannot generate correctly, so a System Bad notice alert will result.

(Requested)

Caption: Your Benefits

We are reducing  (1)  benefits as a  (2)  by the amount to which  (3)  entitled on  (4)  own Social Security record. This means  (5)  benefits will now be  (6)  as a  (7)  plus  (8)  on  (9)  own record.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (2) - Systems Generated

Choice 1: (A) wife

Choice 2: (B) husband

Choice 3: (C) widow

Choice 4: (D) widower

Choice 5: (E) mother

Choice 6: (F) father

Choice 7: (G) disabled widow

Choice 8: (H) disabled widower

Choice 9: (I) disabled divorced widow

Choice 10: (J) disabled divorced widower

Fill-in (3) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (5) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (6) - Systems Generated

Choice 1: Money Amount

Fill-in (7) - Systems Generated

Choice 1: (A) wife

Choice 2: (B) husband

Choice 3: (C) widow

Choice 4: (D) widower

Choice 5: (E) mother

Choice 6: (F) father

Choice 7: (G) disabled widow

Choice 8: (H) disabled widower

Choice 9: (I) disabled divorced widow

Choice 10: (J) disabled divorced widower

Fill-in (8) - Systems Generated

Choice 1: Money Amount

Fill-in (9) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

BEN075 RECOMPUTATION PROVISION NOT PROPERLY APPLIED (A88)

(Requested)

Caption: Your Benefits

We found that we owe  (1)  money because we had not given  (2)  credit for earnings  (3)  had after we first figured  (4)  benefit amount. We will send  (5)  a back payment for past months and increase  (6)  monthly benefit amount.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's Name

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

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: Beneficiary's Name

Fill-in (6) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

BEN076 NO BENEFITS PAYABLE FOR THE RETROACTIVE PERIOD (B25)

(Requested)

Caption: Your Benefits

There is a limit on how much we can pay on each Social Security record. We have paid all benefits due for  (1)  .  (2)  not due any money for this period.

Fill-in values:

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

Choice 1: MM/CCYY to MM/CCYY

Choice 2: MM/CCYY

Fill-in (2) - Systems Generated

Choice 1: You are

Choice 2: Beneficiary's Name is

BEN077 202(J) (1) CLAIM - ODD AMOUNT PAYABLE FOR RETROACTIVE PERIOD (B26)

(Requested)

Caption: Your Benefits

There is a limit on how much we can pay on each Social Security record. For  (1)  we have paid all but  (2)  . For this reason, we will pay  (3)  to  (4)  in the next check.

Fill-in values:

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

Choice 1: MM/CCYY to MM/CCYY

Choice 2: MM/CCYY

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

Choice 1: Amount

Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Total amount due

Fill-in (4) - Requested As A Alpha Character or Name

Choice 1: A=you

Choice 2: Name (Name of Beneficiary)

BEN078 W TO D CONVERSION HIGHER BENEFITS POSSIBLE ON OWN OR PRIOR SPOUSE'S RECORD (B34)

(Requested)

Caption: Other Social Security Benefits

 (1)  may be able to get a higher benefit on  (2)  own Social Security record. Also, if  (3)  married before,  (4)  may qualify for a higher benefit on the record of a prior spouse. If  (5)   (6)  may be able to get a higher benefit on  (7)  own or someone else's Social Security record, please contact us.

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 were

Choice 2: he was

Choice 3: she was

Fill-in (4) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (5) - Systems Generated

Choice 1: you think

Choice 2: he thinks

Choice 3: she thinks

Fill-in (6) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (7) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

BEN079 PC JURISDICTION OF CLAIM WHERE INQUIRIES SHOULD BE FORWARDED (B38)

(System Generated)

Caption: If You Have Any Questions

If  (1)  to write to the office that handles  (2)  case, the address is:

 (3) 

 (4) 

 (5) 

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you need

Choice 2: Beneficiary's Name needs

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Choice 4: Beneficiary's name possessive

Fill-in (3) - Systems Generated

PSC Address Line 1

Fill in (4) - Systems Generated

PSC Address Line 2

Fill-in (4) Systems Generated

PSC Address Line 2

Fill-in (5) - Systems Generated

PSC Address Line 3

BEN080 NO PAYMENT AWARD ELECTED TO CONTINUE REDUCED RIB (B42)

(Requested)

Caption: Your Benefits

We approved  (1)  application for disability benefits. However, we will not pay  (2)  these benefits because  (3)  chose retirement benefits instead.  (4)  family would have received less money if  (5)  chose disability benefits.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

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

BEN081 DIB NOT PAID RIB HIGHER (B44)

(Requested)

Caption: Your Benefits

We considered  (1)  application for disability benefits. Although  (2)  eligible for disability benefits, we cannot pay  (3)  because  (4)  already receiving higher retirement benefits.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (2) Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (4) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

BEN082 CONVERSION BENEFIT INCREASE (NO RATES OR DATES) (B45)

(System Generated)

Caption: Your Benefits

 (1)  benefit amount includes the recent increase because of the change in the cost of living.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Your

Choice 2: Beneficiary's name possessive

BEN083 FUTURE ENTITLEMENT INFORMATION FOR TERMINATING YOUNG SPOUSE, B2, B1, etc. (B46)

(Requested)

Caption: Things To Remember

 (1)  may be eligible to get benefits again when  (2)  age 62. The people in any Social Security office will be glad to help  (3)  at that time.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You

Choice 2: Beneficiary Name

Fill-in (2) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (3) - Systems Generated

Choice 1: you

Choice 3: her

BEN084 (B52)

(Requested)

Caption: What We Will Pay

 (1)  still due back payments for past months.  (2)  will receive this money over a period of months. We will start paying this money to  (3)  shortly, and will send  (4)  another letter explaining how we will pay  (5)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You are

Choice 2: Beneficiary Name plus is

Fill-in (2) - Systems Generated

Choice 1: You

Choice 2: He

Choice 3: She

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (4) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

BEN085 SURVIVOR BENEFIT AWARD BASED ON MBR FROM ODO (B54)

(Requested)

Caption: The Basis For Our Decision

We have not yet looked at the facts about  (1)  case which are in an earlier file. We have requested this file from another office. However, because we do not want to hold up  (2)  checks while we get the file, we figured  (3)  benefits using the other facts we had. We will review  (4)  case after we get the file, and let  (5)  know if we need to make any changes.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

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) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

BEN086 GOVERNMENT PENSION FULL OFFSET GP ELIGIBILITY AFTER JUNE 30, 1983 (B69)

(Requested)

Caption: Your Benefits

We reduce Social Security benefits paid to  (1)  if they also receive a government pension based on their own work. We reduce benefits by two-thirds of the amount of the pension.  (2)  benefit is less than two-thirds of the amount of the pension. For this reason, we cannot pay  (3)  .

Fill-in values:

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

Choice 1: (A) husbands or wives

Choice 2: (B) widows or widowers

Fill-in (2) - Systems Generated

Choice 1: Your

Choice 2: Beneficiary's name possessive

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

BEN087 ALLEGED MISINFORMATION NOT UPHELD (B74)

(Requested)

Caption: Your Benefits

 (1)  filed  (2)  application for benefits on  (3)  .  (4)  said  (5)  did not file earlier because we gave misinformation on  (6)  . We can give  (7)  an earlier filing date if:

  •  (8)  did not file for these benefits before  (9)  because we misinformed  (10)  about  (11)  eligibility for these benefits, or the person who acted for  (12)  about  (13)  eligibility for these benefits, and

  •  (14)  did not get benefits  (15)  could have

We looked at the facts and found that we did not misinform  (16)  about  (17)  eligibility for these benefits. Therefore, we're sorry, but  (18)  cannot get an earlier filing date.

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

Choice 4: Beneficiary's Name possessive

Fill-in (3) - Requested As A Date In Format Shown Below

Choice 1: MM/DD/CCYY (date application was filed)

Fill-in (4) - Systems Generated

Choice 1: You

Choice 2: He

Choice 3: She

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: he

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

Choice 1: MM/DD/CCYY (date alleged misinformation was given)

Fill-in (7) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (8) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (9) - Systems Generated (same as Fill -in 3)

Choice 1: MM/DD/CCYY (date application was filed)

Fill-in (10) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (11) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (12) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (13) - Systems Generated

Choice 1: your

Choice 2: his

Fill-in (14) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (15) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (16) - Systems Generated

Choice 1: you

Choice 2: the person who acted for you

Fill-in (17) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (18) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

BEN088 RIGHTS AND RESPONSIBILITIES DIB (G33)

(System Generated)

Caption: Your Responsibilities

The decisions we made on  (1)  claim are based on information  (2)  gave us. If this information changes, it could affect  (3)  benefits. For this reason, it is important that  (4)  changes to us right away. We have enclosed a pamphlet, “What You Need To Know When You Get Social Security Disability Benefits”. It will tell  (5)  what must be reported and how to report. Be sure to read the parts of the pamphlet which explain what to do if  (6)  to work or if  (7)  health improves.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (4) - Systems Generated

Choice 1: you report

Choice 2: he reports

Choice 3: she reports

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (6) - Systems Generated

Choice 1: you go

Choice 2: he goes

Choice 3: she goes

Fill-in (7) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

BEN089 INTRODUCTORY STATEMENT DUAL ENTITLEMENT AWARD AUXILIARY/SURVIVOR PRIMARY BENEFICIARY IN PAY STATUS (G40)

(Requested)

Caption:

We are writing to let  (1)  know that  (2)  entitled to monthly  (3)  benefits on claim number  (4)  beginning  (5)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you

Choice 2: Beneficiary name

Fill-in (2) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

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

Choice 1: (A) wife's

Choice 2: (B) husband's

Choice 3: (C) widow's

Choice 4: (D) widower's

Choice 5: (E) disabled widow's

Choice 6: (F) disabled widower's

Choice 7: (G) disabled divorced widow's

Choice 8: (H) disabled divorced widower's

Choice 9: (I) child's

Choice 10: (J) mother's

Choice 11: (K) father's

Fill-in (4) - Requested As A Language

SSN in format XXX-XX-XXXX

Fill-in (5) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

BEN090 REPLACEMENT NOTICE (M21)

(Requested)

Caption: None

This letter replaces our previous letter (1).

Fill-in values:

Fill-in (1) Requested as a Date in the format shown below or Alpha character

Choice 1: (A) = Null

Choice 2: dated in format MM/DD/CCYY

BEN100 ACCRUED AMOUNT PAID IN INSTALLMENTS (B24)

(Requested)

Caption: Your Benefits

A payment of  (1)  is due from  (2)  through  (3)  .  (4)  will receive this money over a period of months. We will send  (5)   (6)  more each month as part of the regular check  (7)  . We will start paying the extra money with the check  (8)  on  (9)  .

Fill-in values:

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

Total amount due

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

Choice 1: MM/CCYY

Fill-in (3) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (4) - Systems Generated

Choice 1: You

Choice 2: He

Choice 3: She

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

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

Choice 1: Amount of installment

Fill-in (7) - Systems Generated

Choice 1: you already receive

Choice 2: he already receives

Choice 3: she already receives

Fill-in (8) Choice 1: you receive

Choice 2: he receives

Choice 3: she receives

Fill-in (9) - Requested As A Date In Format Shown Below

Choice 1: Date in MM/DD/CCYY

BEN101 (GA6) BOND

(System Generated)

Caption: None

 (1)  been selected to participate in the Benefit Offset National Demonstration (BOND) project.

Fill-in values:

Fill-in (1)

Choice 1: You have

Choice 2: Beneficiary's Name has

BEN102 PAYMENT POSSIBLE TO OTHER FAMILY MEMBERS WHEN PRIMARY BENEFICIARY IS IMPRISONED/CONFINED (G41)

(Systems Generated)

Caption: Your Benefits

Even though  (1)  benefits will stop, we can pay other members of  (2)  family if they are entitled on  (3)  record.

Fill-in values:

Fill-in (1)

Choice 1: Beneficiary's Name possessive

Choice 2: your

Fill-in (2)

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (3)

Choice 1: your

Choice 2: his

Choice 3: her

BEN103 GOVERNMENT PENSION PARTIAL OFFSET GP ELIGIBILITY AFTER JUNE 30, 1983 (B68)

(Requested)

Caption: Your Benefits

We reduce Social Security benefits paid to  (1)  if they also receive a government pension based on their own work. We reduce benefits by two-thirds of the amount of the pension. For this reason, we are reducing  (2)  benefits beginning  (3)  , by  (4)  .

Fill-in values:

Fill-in (1) Request as a one position alpha character

Choice 1: (A) husbands

Choice 2: (B) wives

Choice 3: (C) widows

Choice 4: (D) widowers

Fill-in (2) System Generated

Choice 1: your

Choice 2: Beneficiary's name possessive

Fill-in (3) Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

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

Amount of reduction

BEN104 ONE OR MORE CHECKS WITHHELD (M17)

(Requested)

Caption: Your Benefits

Therefore we are withholding  (1)   (2)   (3)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: her

Choice 3: him

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

Choice 1: (A) check

Choice 2: (B) checks

Fill-in (3) - Requested As A Date In Format Shown Below

Choice 1: for MM/CCYY

Choice 2: for MM/CCYY and MM/CCYY

Choice 3: for MM/CCYY through MM/CCYY

BEN105 BOND NOTIFICATION OF ADJUSTMENT

(Requested)

Caption: None

We may have let  (1)  know earlier that we would increase  (2)  benefits to  (3)  per month due to the rise in the cost of living. We have refigured  (4)  benefits based on  (5)  participation in the benefit offset national demonstration project (BOND). This notice corrects the calculation to apply the cost of living increase to  (6)  original benefit before the reduction for BOND earnings.  (7)  new monthly amount (before deductions) is  (8)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you

Choice 2: Name

Fill-in (2) - System Generated

Choice 1: your

Choice 2: Name possessive

Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Amount (BRI/MBR incorrect monthly benefit amount)

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: Name possessive

Fill-in (5) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (6) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (7) - Systems Generated

Choice 1: Your

Choice 2: Name possessive

Fill-in (8) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Amount (new offset monthly benefit amount)

BEN106 BOND – EOYR Adjustment

(Requested)

Caption: Your Benefits

Based on  (1)  earnings of  (2)  for  (3)  we should have paid  (4) 

Amount Date

 (5)   (6) 

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Name possessive

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

Choice 1: Amount (End of year BOND amount)

Fill-in (3) - Requested As A Date In Format Shown Below

Choice 1: CCYY

Choice 2: CCYY and CCYY

Fill-in (4) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

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

Choice 1: Amount (MBC in $$$$$.¢¢ format)

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

Choice 1: MM/CCYY

Choice 2: MM/CCYY through MM/CCYY

BEN107 BOND EOYR

(Requested)

Caption: Your Benefits

This means we paid  (1)  correctly based on the evidence  (2)  provided for the reconciliation year.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you

Choice 2: Name

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

BEN108 BOND EOYR Overpayment or Underpayment

(Requested)

Caption: Your Benefits

This  (1)  resulted from the difference in the yearly amount that  (2)  estimated  (3)  would earn during  (4)  and the actual amount that  (5)  earned, during that year. We determined the  (6)  after we recalculated  (7)  offset amount based on  (8)  actual BOND countable earnings.

Fill-in values:

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

Choice 1: (A) overpayment

Choice 2: (B) underpayment

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: Name

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (4) - Requested As A Date In Format Shown Below

Choice 1: Date (Recon year in CCYY format)

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (6) - Requested As A One Position Alpha Character (same as Fill-in 1)

Choice 1: (A) overpayment

Choice 2: (B) underpayment

Fill-in (7) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (8) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

BEN109 BOND – No Longer Eligible For BOND Project – Term Date

(Requested)

Caption: Your Benefits

 (1)  been a participant in the Benefit Offset National Demonstration (BOND) project. The special rules for the BOND project will no longer apply to  (2)  beginning  (3)  .  (4)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You have

Choice 2: Name has

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (3) - Requested As A Date In Format Shown Below

Choice 1: MM/DD/CCYY

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

Choice 1: (A) You asked to be withdrawn from the project. If you are receiving benefit payments based on disability, your payments may stop the first month you do substantial gainful work.

Choice 2: (B) He asked to be withdrawn from the project. If he is receiving benefit payments based on disability, his payments may stop the first month he does substantial gainful work.

Choice 3: (C) She asked to be withdrawn from the project. If she is receiving benefit payments based on disability, her payments may stop the first month she does substantial gainful work.

Choice 4: (D) You are no longer eligible for the project, because you have not completed the trial work period by September 30, 2017.

Choice 5: (E) He is no longer eligible for the project, because he has not completed the trial work period by September 30, 2017.

Choice 6: (F) She is no longer eligible for the project, because she has not completed the trial work period by September 30, 2017.

Choice 7: (G) null

BEN110 BOND – No Longer Eligible For BOND Project - Explanation

(Requested)

Caption: Your Benefits

 (1)  no longer eligible for the project because  (2)   (3)  . If  (4)  receiving benefit payments based on disability,  (5)  payments may stop the first month  (6)  substantial gainful work.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You are

Choice 2: Name is

Fill-in (2) - Systems Generated

Choice 1: you have

Choice 2: he has

Choice 3: she has

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

Choice 1: (A) had benefits terminated prior to the BOND start date of participation

Choice 2: (B) participated in another demonstration project before

Choice 3: (C) moved to a foreign country

Choice 4: (D) received benefits paid by the railroad

Choice 5: (E) elected to receive benefits not based on a disability

Choice 6: (F) no longer met the BOND eligibility criteria

Fill-in (4) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (5) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (6) - Systems Generated

Choice 1: you do

Choice 2: he does

Choice 3: she does

BEN111 BOND Participation End Date

(Requested)

Caption: Your Benefits

 (1)  participation period ends  (2)  . Payments may end with the month  (3)  substantial gainful work after  (4)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Your

Choice 2: Name possessive

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

Choice 1: MM/CCYY

Fill-in (3) - Systems Generated

Choice 1: you do

Choice 2: he does

Choice 3: she does

Fill-in (4) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

BEN112 BOND Participation End Date SGA

(Requested)

Caption: Your Benefits

 (1)  participation period ends  (2)  . Since  (3)  not demonstrated an ability to perform work at a substantial gainful activity (SGA) level, payments may end in the second month following the month  (4)  an ability to perform work at an SGA level.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Your

Choice 2: Name possessive

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

Choice 1: MM/CCYY

Fill-in (3) - Systems Generated

Choice 1: you have

Choice 2: he has

Choice 3: she has

Fill-in (4) - Systems Generated

Choice 1: you demonstrate

Choice 2: he demonstrates

Choice 3: she demonstrates

BEN113 BOND Special Rules

(Requested)

Caption: What Happens When The Special Rules For BOND No Longer Apply

The special rules for the BOND project will no longer apply to  (1)  after  (2)  participation period ends. If  (3)  benefit payments based on disability after that month,  (4)  payments will stop the first month  (5)  substantial gainful work.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you

Choice 2: Name

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (3) - Systems Generated

Choice 1: you receive

Choice 2: he receives

Choice 3: she receives

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (5) - Systems Generated

Choice 1: you do

Choice 2: he does

Choice 3: she does

BEN114 BOND Adjustment

(Requested)

Caption: Why We Cannot Pay You

We cannot pay  (1)  benefits for  (2)  under the rules of the Benefit Offset National Demonstration (BOND) project. This is due to  (3)  work and earnings. This does not change any current benefits  (4)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you

Choice 2: Name

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

Choice 1: MM/CCYY

Choice 2: MM/CCYY through MM/CCYY

Fill-in (3) - Requested As A Language

Choice 1: Name (BOND participant)

Fill-in (4) - Systems Generated

Choice 1: you receive

Choice 2: he receives

Choice 3: she receives

BEN115 BOND Refund

(Requested)

Caption: None

 (1)  will soon receive a check for  (2)  . This check is for benefits due to  (3)  for  (4)  under the rules of the Benefit Offset National Demonstration (BOND) project.  (5)  due this check because of  (6)  work and earnings. This does not change any current benefits  (7)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You

Choice 2: Name

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

Choice 1: Amount (refund amount)

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (4) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Choice 2: MM/CCYY through MM/CCYY

Fill-in (5) - Systems Generated

Choice 1: You are

Choice 2: Name is

Fill-in (6) - Requested As A Language

Choice 1: Name (BOND participant)

Fill-in (7) - Systems Generated

Choice 1: you receive

Choice 2: he receives

Choice 3: she receives

BEN116 BOND Project Contact Information

(Requested)

Caption: Your Benefits

If  (1)  working and  (2)  not given us an estimate of  (3)  expected yearly earnings, please contact Abt Associates immediately. We show their contact information under the heading, “If You Have Questions About the BOND Project”. If  (4)  not give us an estimate, we may pay  (5)  incorrect benefit payments.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you are

Choice 2: Name is

Fill-in (2) - Systems Generated

Choice 1: have

Choice 2: has

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (4) - Systems Generated

Choice 1: you do

Choice 2: he does

Choice 3: she does

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

BEN117 BOND Informational (No Change)

(Requested)

Caption: None

Thank you for giving us information about  (1)  earnings for last year.  (2)  asked us to determine if there has been a change in the amount of benefits payable to  (3)  under BOND because of this information. Based on this evidence we have determined that there is no change to  (4)  monthly benefit amount for this period. This decision does not change any benefits  (5)  may be currently receiving.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Name possessive

Fill-in (2) - Systems Generated

Choice 1: You

Choice 2: He

Choice 3: She

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

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

BEN118 BOND Informational

(Requested)

Caption: Your Benefits

Thank you for giving us information about  (1)  earnings for the last year.  (2)  asked us to determine if there has been a change in the amount of benefits payable to  (3)  under BOND because of this information.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Name possessive

Fill-in (2) - Systems Generated

Choice 1: You

Choice 2: He

Choice 3: She

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

BEN119 BOND Request/Decision

(Requested)

Caption: None

We received a request  (1)  .

Fill-in values:

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

Choice 1: (A) for an explanation

Choice 2: (B) that we not collect the overpayment

Choice 3: (C) that we review our decision

Choice 4: (D) that we review our decision and not collect the overpayment

Choice 5: (E) that we withhold a different amount


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900720060
NL 00720.060 - BEN Benefit Information - 05/20/2015
Batch run: 05/20/2015
Rev:05/20/2015