TN 2 (09-11)

NL 00720.250 PAY Payment

PAY032 DUAL ENTITLEMENT (CHECKS COMBINED) — AUXILIARY/SURVIVOR AWARD AFTER PRIMARY (A42)

(Requested)

Caption: What We Will Pay

 (1)  benefit is  (2)  as a  (3)  . This is in addition to the benefit of  (4)  on  (5)  own earnings record.

Fill-in values:

Fill-in (1) Systems Generated

Choice 1: Your

Choice 2: His

Choice 3: Her

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

Amount

Fill-in (3) 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) disable widower

Choice 9: (I) disabled divorced widow

Choice 11: (J) disabled divorced widower

Choice 12: (K) child

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

Amount

Fill-in (5) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

PAY067 PMA PAYMENT REDUCED BY AMOUNT OF CRITICAL PAYMENT (B55)

(System Generated)

Caption: What We Will Pay

We will subtract  (1)  from your next check. This is the amount we paid you before we finished work on  (2)  claim.

Fill-in values:

Fill-in (1)

CPA in format 99,999.99

Fill-in (2)

Choice 1: your

Choice 2: Beneficiary's Name Possessive

PAY068 CMA ONLY PAYMENT DUE - CRITICAL PAYMENT DEDUCTION MADE (B58)

(System Generated)

Caption: What We Will Pay

When we figured how much to pay you through  (1)  , we subtracted the money which we already paid you while we finished work on  (2)  claim.

Fill-in values:

Fill-in (1)

If LAF equals C: CMA minus one month in format January 1993. If LAF does not equal C: find first EFD with equal RFD to current LAF and is greater than DOEC. This Fill-ins is EFD minus one month in format January 1993.

Fill-in (2)

Choice 1: your

Choice 2: full name Possessive

PAY072 EXPLANATION THAT FIRST CHECK INCLUDES AN INSTALLMENT AMOUNT (B50)

(Requested)

Caption: What We Will Pay

This check includes  (1)  regular monthly payment of  (2)  for  (3)  .

Fill-in values:

Fill-in (1) Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (2) Systems Generated

Amount

Fill-in (3) Systems Generated

Month and Year

PAY073 PAYMENT OF PAST-DUE BENEFITS WILL BE PAID IN INSTALLMENTS (B51)

(Requested)

Caption: What We Will Pay

 (1)  still due back payments of  (2)  for past months.  (3)  will receive this money over a period of months. We will send  (4)   (5)  more each month with  (6)  regular payment until all of the extra money is paid.

Fill-in values:

Fill-in (1) Systems Generated

Choice 1: You are

Choice 2: He is

Choice 3: She is

Fill-in (2) Systems Generated

amount of past due benefit payable

Fill-in (3) Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (4) Systems Generated

amount of installment

Fill-in (5) Systems Generated

Choice 1: your

Choice 2: her

Choice 3: his

Fill-in (6) Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

PAY161 CMA or MBP = $0.00 After Adjustments (G07)

(System Generated)

Caption: None

No payment is due at this time because of adjustments made to  (1)  benefits.

Fill-in values:

Fill-in (1)

Choice 1: his

Choice 2: her

Choice 3: your

Choice 4: Beneficiary's Name

PAY176 IRMAA – CHANGE RESULTS IN PREMIUM REFUND (HB2)

(Requested/Generated)

Caption: What We Will Pay and Why

Based on the information we have,  (1)   (2)  due a Medicare Part B premium refund.

Fill-in values:

Fill-in (1) Systems Generated

Choice 1: Beneficiary's Name

Choice 2: you

Fill-in (2) Systems Generated

Choice 1: is

Choice 2: are

PAY180 CHECK PARAGRAPH USED WHEN ARF AND/OR DRC NOT PROPERLY APPLIED (B20)

(System Generated)

Caption: What We Will Pay

 (1)  next check for  (2)  includes additional benefits through  (3)  .

After that,  (4)  will receive a new regular monthly payment of  (5)  .

Fill-in values:

Fill-in (1)

Choice 1: Your

Choice 2: Beneficiary's name possessive

Fill-in (2)

Amount

Fill-in (3)

Month/Year (PMA)

Fill-in (4)

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (5)

Amount of new MPA

PAY181 PAYMENT RESUMED AFTER SOME WITHHOLDING (M15)

(Requested)

Caption: Your Benefits

Since we withheld  (1)  , we can pay  (2)  beginning  (3) 

Fill-in values:

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

Amount

Fill-in (2) Systems Generated

Choice 1: you

Choice 2: Beneficiary's name

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

MM/CCYY

PAY182 PAYMENT STOPPED (M16)

(Requested)

Caption: Your Benefits

We are stopping  (1)  benefits beginning  (2)  .

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 Shown Below

MM/CCYY

PAY183 ADDITIONAL WITHHOLDING REQUIRED (M18)

(Requested)

Caption: Your Benefits

Since we withheld  (1)  , we must withhold  (2)  more.

Fill-in values:

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

Amount

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

Amount

PAY184 INCORRECT EARNINGS OVERPAYMENT CAUSED BY REDUCTION IN BENEFIT AMOUNT (M26)

(Requested)

Caption: Your Benefits

We reviewed our records, and found that a mistake was made when  (1)  benefit amount was increased. In  (2)   (3)  earned  (4)  instead of  (5)  , which was the amount we used when we figured  (6)  payment. We have now corrected our records, and found that we paid  (7)   (8)  too much in benefits.

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 Shown Below

CCYY erroneous earnings posted

Fill-in (3) Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

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

Amount of correct earnings

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

Amount of incorrect earnings

Fill-in (6) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (7) Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

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

Amount of overpayment

PAY212 INITIAL PARTIAL AWARD/PARTIAL MONTH BENEFITS PAID (B78)

(Requested)

Caption: Your Benefits

We used  (1)   (2)   (3)   (4)   (5)  to decide how much to pay  (6)  . We are still working on  (7)  claim. When we make a final decision about the  (8)  , we will figure the amount of  (9)  payments. We will send you another letter to let you know if there will be any change in  (10)  payments.

Fill-in values:

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

Choice 1: (A) a date of birth of

Choice 2: (B) a date of marriage of

Choice 3: (C) wages through

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

Choice 1: MM/CCYY

Choice 2: MM/DD/CCYY

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

Choice 1: (A) for

Choice 2: (B) null

Fill-in (4) Systems Genera