TN 4 (08-12)

NL 00720.125 DIB Disability

DIB002 PARTIALLY FAVORABLE DETERMINATION DIB CLAIM (J06)

(Requested)

Caption: The Basis For Our Decision

We recently told you that  (1)  met the medical requirements to receive Social Security benefits. Now we are writing to tell you that  (2)   (3)  the other requirements. Therefore,  (4)   (5)  for  (6)  beginning  (7)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you

Choice 2: Fullname

Fill-in (2) - Systems Generated

Choice 1: he

Choice 2: she

Choice 3: you

Fill-in (3) - Systems Generated

Choice 1: meet

Choice 2: meets

Fill-in (4) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (5) - Systems Generated

Choice 1: qualify

Choice 2: qualifies

Fill-in (6) - Systems Generated

Choice 1: period of disability

Choice 2: monthly disability benefits from Social security

Fill-in (7) - Systems Generated

Choice 1: date of entitlement to disability

DIB003 ONE-CHECK-ONLY AWARD CLOSED PERIOD (J12)

(Requested)

Caption: The Date You Became Disabled

We determined that  (1)  disability ended  (2)  . The first month that we could pay  (3)  benefits was  (4)  . We could pay  (5)  through the month  (6)  disability ended and the next two months. This means that the last month for which  (7)  entitled to benefits was  (8)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Name Possessive

Choice 2: your

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

Choice 1: MM/CCYY

Fill-in (3) - Systems Generated\

Choice 1: her

Choice 2: him

Choice 3: you

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

Choice 1: MM/CCYY

Fill-in (5) - Systems Generated

Choice 1: her

Choice 2: him

Choice 3: you

Fill-in (6) - Systems Generated

Choice 1: her

Choice 2: his

Choice 3: your

Fill-in (7) - Systems Generated

Choice 1: she was

Choice 2: he was

Choice 3: you were

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

Choice 1: MM/CCYY

DIB004 SSA PHYSICIAN PARTICIPATED IN DECISION STATE CASE (T28)

(Requested)

Caption: The Basis For Our Decision

Doctors and other trained personnel made the disability decision for us. They work for  (1)  State but used our rules to make their decision.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Fullname possessive

DIB005 SSA PHYSICIAN PARTICIPATED IN DECISION NON STATE CASE (T29)

(Requested)

Caption: The Basis For Our Decision

Our doctors and other trained personnel made the disability decision in  (1)  case.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Full name possessive

DIB072 FIVE MONTH WAITING PERIOD (J09)

(Requested)

Caption: The Date You Became Disabled

 (1)  to be disabled for 5 full calendar months in a row before