BASIC (05-11)

NL 00720.140 DTH Death

DTH009 LUMP-SUM DEATH PAYMENT INCLUDED WITH BENEFITS (B01)

(Requested)

Caption: What We Will Pay

 (1)  first check includes a lump-sum payment of  (2)  . This is a one-time payment we make because of a worker's death.

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 of LSDP

DTH010 LUMP SUM ONLY SURVIVOR BENEFITS SUSPENDED OR TERMINATED (B04)

(Requested)

Caption: What We Will Pay

 (1)  will soon receive a check for  (2)  . This is a one-time payment we make because of a worker's death. It is the only money  (3)  due now.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's Name

Fill-in (2) - Systems Generated

Choice 1: Amount of LSDP

Fill-in (3) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

DTH011 COMBINED CHECK FOR MONTH OF DEATH WITHHELD FROM WIDOW(ER) RECEIVING FIRST BENEFIT PLUS LUMP-SUM (B05)

(Requested)

Caption: What We Will Pay

This check includes  (1)  , the money  (2)  due for  (3)  . It also includes a lump-sum payment of  (4)  . This is a one-time payment we make because of a worker's death.

We subtracted  (5)  from these benefits. We did this to recover money from the combined check which we sent for the month  (6)  died.

Fill-in values:

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

Choice 1: Amount of past due benefits

Fill-in (2) - Systems Generated

Choice 1: you are

Choice 2: Beneficiary's Name +is

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

Choice 1: MM/CCYY

Choice 2: MM/CCYY through MM/CCYY

Fill-in (4) - Systems Generated

Choice 1: Amount of lump-sum

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

Choice 1: Amount of reduction

Fill-in (6) - Systems Generated

Choice 1: Full name of NH

DTH012 CATEGORY M PAYMENT REASON AND AMOUNT - INTRODUCTORY PARAGRAPH (G58)

(System Generated)

Caption:

We are sorry to learn of  (1)  loss. Please accept our sincere sympathy.

 (2)  entitled to a Social Security payment because of the death of  (3)  .  (4)  will receive this payment soon.

The amount of the check is  (5)  .

Fill-in values:

Fill-in (1)

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (2)

Choice 1: You are

Choice 2: He is

Choice 3: She is

Fill-in (3)

Choice 1: Name of deceased person

Fill-in (4)

Choice 1: You

Choice 2: He

Choice 3: She

Fill-in (5)

Choice 1: Amount of past due benefits


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900720140
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