TN 21 (10-17)

NL 00725.005 Modernized Claims Systems (MCS) Universal Text Identifiers (UTIs)

A. List of all MCS UTI alpha designations

AET

Annual Earnings Test

AGE

Age

ALS

Appeals

APP

Applicant Statements

ATY

Attorney Fee

BEN

Benefit Information

BRR

Beneficiary Reporting Responsibilities

CDR

Continuing Disability Review

CIC

Child In Care

CLO

Closeout

COL

Cost of Living

COP

Copy of Notice

CTZ

Citizenship

DAA

Drug Addiction and Alcoholism

DDD

Disability Date Denials

DEP

Dependents

DIB

Disability

DSL

Disallowance

ENC

Enclosure

ENT

Entitlement

ERN

Earnings

FOB

Filing for Other Benefits

FRZ

Freeze

FUG

Fugitive Felon

FWK

Foreign Work

GAR

Garnishment

GPO

Government Pension Offset

HIB

Health Insurance Benefits

IDN

Identification

INF

Reminder/Informational

INS

Insured Status

ISC

Payment Summary

LSP

Lump Sum Payment

MAR

Marriage

MHP

Medicare Health Plan

MIS

Miscellaneous

MOE

Month of Entitlement

MPD

Income Related Monthly Reduction Amount

MSV

Military Service

ONS

Disability Onset Paragraphs

PAY

Payment

PMT

Payment Cycling

PRI

Prisoner Provisions

RDE

Rate Decrease

REC

Reconsideration Decision

REF

Referral

REL

Family Relationship

REP

Attorney Representation

RIN

Rate Increase

RPY

Representative Payee

RRB

Railroad Retirement Board

RSD

Residence

SEI

Self-Employment Income

SSA

Headings and Signatures

STU

Student Status

SUS

Suspensions deleted (for other than work)

TAX

Taxation of Benefits

TER

Terminations

TOT

Totalization

TWP

Trial Work Period

VRN

Vocational Rehabilitation

VTW

Voluntary Tax Withholding

WCP

Workers' Compensation

WDS

Work & Earnings facility of payment

WDW

Withdrawal

WEP

Windfall Elimination Provision

WFO

Windfall Offset

B. List of all MCS UTIs with the text

We listed the text for all MCS UTIs.

AAAD01 Dictated Text

AETC03 Caption

Work and Earnings Affect Payments

AETD03 Dictated Text

AET002 LMETY Year Established, Earnings Reported

The monthly earnings test applies only to 1 year. That year is the first year a beneficiary has a non-work month after entitlement to Social Security benefits. Our records show that  (1)  had or will have at least one non-work month in  (2)  . Therefore, we will pay  (3)  benefits for years after  (4)  based on the total amount  (5)   (6)  each year.

Fill-ins:

(1) FN

(2) LMETY year

(3) PN

(4) LMETY year

(5) PN

(6) “earn”/“earns”

AET003 LMETY Established, No Earnings Reported

The monthly earnings test applies only to 1 year. That year is the first year a beneficiary has a non-work month after entitlement to Social Security benefits. Our records show that  (1)  had or will have at least one non-work month in  (2)  . If  (3)  ever  (4)  to work, we will pay benefits for each year based on  (5)  work and earnings for that year.

Fill-ins:

(1) FN

(2) LMETY year

(3) “you”/“he”/“she”

(4) “go”/“goes”

(5) “your”/“her”/“his”

AETR32 Future Auxiliary Benefits – Disadvantageous for Spouse to File While Number Holder in Suspense Due to Work

 (1)   (2)  might qualify for benefits on  (3)  record when  (4)   (5)  working or  (6)   (7)  earnings. However,  (8)  will have to file an application for these benefits. The filing date can make a difference in the amount of benefits we pay.  (9)  should get in touch with us about filing as soon as  (10)   (11)  working or  (12)   (13)  earnings.

Fill-ins:

(1) SN possessive

(2) “wife”/“husband”

(3) PN

(4) “you/“she”/“he”

(5) “stop”/“stops”

(6) “reduce”/“reduces”

(7) “your”/“her”/“his”

(8) SN of spouse *

(9) “She”/“He”

(10) NHSN

(11) “stop”/“stops”

(12) “reduce”/“reduces”

(13) “your”/“her”/“his”

(*) indicates that the fill-ins are manual

AET055 Benefits for All or Part of a Calendar Year Due to Earnings

We are withholding  (1)  of  (2)  benefits for  (3)  because of  (4)  work and earnings.

Fill-ins:

(1) total amount of monthly benefits to be withheld for the year in format $NNNNN.NN

(2) SN possessive/ “your”

(3) month & year in format “Month YYYY”/ month & year and month year in format “Month YYYY and Month YYYY” /month & year through month/year in format “Month YYYY through Month YYYY”

(4) “her”/“his”/“your”

AET057 Earnings are Reported for a Prior, Current or Future Year that is Not a Closed Year

 (1)  estimated that  (2)  would earn $  (3)  in  (4)  .

Fill-ins:

(1) You

(2) SN/you

(3) estimate amount in format $NNNNN.NN

(4) year in the format YYYY

AET058 Earnings are Reported for 2 Prior, Current or Future Years that are Not Closed Years

 (1)  estimated that  (2)  would earn $  (3)  in  (4)  and $  (5)  in  (6)  .

Fill-ins:

(1) You

(2) SN/you

(3) estimate amount in format “$NNNNN.NN”

(4) year in the format “YYYY”

(5) estimate amount in format “$NNNNN.NN”

(6) year in the format “YYYY”

AET059 Earnings are Reported for 1 Or 2 Prior, Current or Future Years that are Not Closed Years and One of the Aforementioned Years is Equal to the BCLM-LMETY

This UTI Will be Used in Tandem with Either AET057 (When 1 Year is Involved) or AET058 (When 2 Years are Involved)

You also said that  (1)  would not earn more than $  (2)   (3)  and would not be active in self-employment in  (4)   (5)   (6)   (7)   (8)   (9)   (10)   (11)  .

Fill-ins:

(1) “you”/“she”/“he”

(2) monthly exempt amount in the format “$$$.¢¢”

(3) If more than one non-service month, add “per month”/otherwise, null

(4) earliest non-service month in the format “April”

(5) “and”/“through”/null

(6) null/non-service month in format “June”

(7) “and”/“through”/null

(8) non-service month in format “July”/null

(9) null/“and”/“through”

(10) null/non-service month in format “August”

(11) show LMETY in format “1988”

AET060 One Year of Temporary Deductions and No Year with Permanent Deductions

 (1)  are withholding  (2)  of  (3)  benefits for  (4)   (5)   (6)   (7)   (8)   (9)   (10)   (11)  because of work and earnings.

Fill-ins:

(1) We

(2) “all”/ Total MBC withheld due to work in format “$$$$.¢¢”

(3) SN possessive

(4) year in format “1988”/month in format “January”

(5) “and”/“through”/null

(6) month in format “April”/null

(7) “and”/null

(8) month in format “June”/null

(9) “and”/“through”/null

(10) month in format “September”/null

(11) year in format “1988”/null

AET061 There are Two Years of Temporary Deductions and No Year with Permanent Deductions

Also, we are withholding  (1)  of  (2)  benefits for  (3)   (4)   (5)   (6)   (7)   (8)   (9)   (10)  .

Fill-ins:

(1) “all”/ Total MBC withheld due to work in format “$NNNN.NN”

(2) SN possessive

(3) year in format “1988”/month in format “January”

(4) “and”/“through”/null

(5) month in format “April”/null

(6) “and”/null

(7) month in format “June”/null

(8) “and”/“through”/null

(9) month in format “September”/null

(10) year in format “1988”/null

AET062 There are Either One or Two Years of Permanent Deductions Due to Work and Earnings

We  (1)  pay  (2)   (3)  benefits for  (4)   (5)   (6)   (7)   (8)   (9)   (10)   (11)   (12)   (13)   (14)   (15)  because  (16)  work.

Fill-ins:

(1) “cannot”

(2) SN

(3) “full”/“any”

(4) year in format “1988”/month and year in format January “1988”/month in format “January”

(5) “and”/“through”/null

(6) month in format “December”/null

(7) “and”/null

(8) month in format “May”/null

(9) “and”/“through”/null

(10) month in format “July”/null

(11) year/null

(12) “and we can pay only”/null

(13) MBC in format “$99,999.99” or “$99,999” (no cents)/null

(14) “for”/null

(15) month and year in the format “August 2008”/null

(16) “your”/“her”/“his”/SN possessive

AET063 There is at Least One Year of Permanent Work Deductions and One Year Where Temporary Work Deductions are Applicable

We  (1)  pay  (2)   (3)  benefits for  (4)   (5)   (6)  because of  (7)  work and earnings. Also, we are withholding  (8)  of  (9)  benefits for  (10)   (11)   (12)  because of work and earnings.

Fill-ins:

(1) “cannot”

(2) SN

(3) “full”/“any”

(4) year/month and year/month

(5) “and”/“through”/null

(6) month and year/month/null

(7) “your”/“her”/“his”

(8) “all”/total MBC in format “$99,999.99” or “$99,999”, no cents

(9) “your”/“her”/“his”

(10) year/month

(11) “and”/“through”/null

(12) month/null

AGE004 Disallowance, Age

 (1)   (2)  not qualify for  (3)  benefits now because, based on  (4)   (5)  ,  (6)  ,  (7)  not yet age  (8)  .

Fill-ins:

(1) SN (First letter capitalized)

(2) “do”/“does”

(3) “retirement”

(4) SN/null

(5) “the date of birth that was given to us”/“correct date of birth”/“date of birth”

(6) month/day/year

(7) “you are”/“she is”/“he is”

(8) “62”/“60”/“50”

AGE005 Disallowance, Child (Age)

 (1)  not qualify for child's benefits because  (2)  : over age 18, and not disabled, and not a full-time elementary or secondary level school student.

Fill-ins:

(1) FN

(2) “she is”/“he is”

AGE006 Age Factor - DOB Not Established

 (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-ins:

(1) “You”/SN in format “Mr. Jones”

(2) “do”/“does”

(3) Type of benefit

(4) “you have”/“she has”/“he has”

(5) “62”/“60”/“50”

(6) “your”/“her”/“his”

AGE007 Medicare Disallowance, Age

 (1)  must be at least age 65 to qualify for Medicare. Based on  (2)  ,  (3)  ,  (4)  not old enough.

Fill-ins:

(1) “you”/“she”/“he”

(2) “the date of birth that was given to us”/“[2a] or [2b] date of birth”/“[2a] SN possessive birth date”/“[2b] correct birth date”/null

(3) birth date (MM/DD/YYYY)

(4) “you are”/“she is”/ “he is”

AGE008 Established Date of Birth Different from Alleged

Based on the evidence we have, we have decided that  (1)  correct date of birth is  (2)  .

Fill-ins:

(1) FN

(2) Month/day/year

AGER09 Foreign Birth Record Not Readily Available

To pay benefits more quickly, we use  (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-ins:

(1) alleged date of birth in the format “Month DD, YYYY” *

(2) “your” or beneficiary's full name in the format “Mr. Jack Jones”

(3) “you”/“she”/“he”

(4) “your”/“her”/“his”

(*) indicates that the fill-ins are manual

ALSC02 Caption

Do You Disagree With the Decision?

ALSC05 Caption

How The Hearing Process Works

ALSC08 Caption

It Is Important To Go To The Hearing

ALSC12 Caption

If You Disagree With The Decisions

ALSC26 Caption

About The Appeals

ALSC27 Caption

If You Want To Appeal

ALSC28 Caption

If You Ask For A Reconsideration And A Hearing

ALS023 Appeals Language – Powell Decision

If you do not agree with this decision, you have the right to appeal. We will review  (1)  case and look at any new facts you have. A person who did not make the first decision will decide  (2)  case. We will review the parts of the decision that you think are wrong and correct any mistakes. We may also review the parts of our decision that you think are right. We will make a decision that may or may not be in  (3)  favor.

You have 60 days to ask for an appeal.

The 60 days start the day after you receive this letter. We assume you received this letter 5 days after the date on it unless you show us that you did not receive it within the 5-day period.

You must have a good reason if you wait more than 60 days to ask for an appeal.

You can file an appeal with any Social Security office. You must ask for an appeal in writing. Please use our “Request for Reconsideration” form, SSA-561-U2. You may go to our website at  (4)  to find the form. You can also call, write, or visit us to request the form. If you need help to fill out the form, we can help you by phone or in person.

Fill-ins:

(1) “your”/name, possessive

(2) “your”/”his”/”her”

(3) “your”/”his”/”her”

(4) www.socialsecurity.gov/online/

ALS040 Appeals Language – Administrative Law Judge

If you disagree with our decision, you have the right to request a hearing. A person who has not seen  (1)  case before will look at it. That person is an Administrative Law Judge. The Administrative Law Judge will review our decisions and look at any new facts you have.

Fill-in:

(1) SN

ALS041 Appeals Language – Res Judicata

If there are no new facts, the judge may find that the application presents the same issues as the prior application, and dismiss the hearings request.

ALS042 Hearing Appeals Period

You have 60 days to ask for a hearing.

The 60 days start the day after you receive this letter. We assume you received this letter 5 days after the date on it unless you show us that you did not receive it within the 5-day period.

You must have a good reason if you wait more than 60 days to ask for a hearing.

You can file a hearing with any Social Security office. You must ask for a hearing in writing. Please use our “Request for Hearing” form, HA-501. You may go to our website at  (1)  to find the form. You can also call, write, or visit us to request the form. If you need help to fill out the form, we can help you by phone or in person.

If you want to make a request, please contact one of our offices. We can help you complete the required form.

Please read the enclosed pamphlet, “Your Right to an Administrative Law Judge Hearing and Appeals Council Review of Your Social Security Case.” It contains more information about the hearing.

ALS043 Appeals Language – Hearings Request – Living in Foreign Country

You have 60 days to ask for a hearing.

The 60 days start the day after you receive this letter.

You must have a good reason if you wait more than 60 days to ask for a hearing.

You can only have a hearing in the United States. You would have to pay any costs for traveling to the United States for the hearing. If you cannot come to the hearing, the ALJ will review your case plus any new information you send us. We will send you a letter about the ALJ's decision.

You have to ask for a hearing in writing. Contact us if you want help.

ALS046 Reconsideration Hearing for Domestic and Foreign Appeals Cases

This action results from reconsideration of your claim and replaces our previous determination.

If you think we are wrong, you have the right to request a hearing. At the hearing, a person who has not seen your case before will look at it. That person is an Administrative Law Judge. In the rest of our letter, we will call this person an ALJ. The ALJ will review those parts of the decision which you believe are wrong. The ALJ will look at any new facts you have and correct any mistakes. The ALJ may also review those parts which you believe are correct and may make them unfavorable or less favorable to you.

ALS047 ALJ Level; Supersedes Previous Determination; Domestic and Foreign

We previously informed you of your appeal rights concerning the administrative law judge's (ALJ) decision. We also informed you of what you must do to have that decision reviewed.

If you believe that we decided any other part of  (1)  case incorrectly, you may request reconsideration on that part of  (2)  case.

Fill-ins:

(1) “your”/”his”/”her”

(2) “your”/”his”/”her”

ALS048 Domestic ALJ Cases; If ALS047 and SCC Present

If you do not agree with this decision, you have the right to appeal. We will review  (1)  case and look at any new facts you have. A person who did not make the first decision will decide  (2)  case. We may also review the parts of the decision that you think are right. We will make a decision that may or may not be in  (3)  favor.

You have 60 days to ask for an appeal.

The 60 days start the day after you receive this letter. We assume you received this letter 5 days after the date on it unless you show us that you did not receive it within the 5-day period.

You must have a good reason if you wait more than 60 days to ask for an appeal.

You can file an appeal with any Social Security office. You must ask for an appeal in writing. Please use our “Request for Reconsideration” form, SSA-561-U2. You may go to our website at  (4)  to find the form. You can also call, write, or visit us to request the form. If you need help to fill out the form, we can help you by phone or in person.

Fill-ins:

(1) “your”/name, possessive

(2) “your”/”his”/”her”

(3) “your”/”his”/”her”

(4) www.socialsecurity.gov/online/

ALS049 Foreign ALJ Cases; If ALS047 and Consul Code Present

If you want this reconsideration, you must request it not later than 60 days from the date you receive this notice. You may make your request to the Social Security Administration, P.O. Box 17769, Baltimore, Maryland 21235, U.S.A. If additional evidence is available, you should submit it with your request.

If you live in Canada or Mexico, you may also make your request through any Social Security office. Residents of the Philippines may contact the Veterans Affairs Regional office, SSA Division, 1131 Roxas Boulevard, Manila. Residents of all other countries may contact the nearest United States Diplomatic or Consular Office.

ALS054

It is very important that you go to the hearing. If for any reason you can't go, contact the ALJ as soon as possible before the hearing and explain why. The ALJ will reschedule the hearing if you have a good reason.

If you don't go to the hearing and don't have a good reason for not going, the ALJ may dismiss your request for a hearing.

ALS061

This action supersedes our previous determination and is in accordance with the decision on your hearing request. You have already been notified of your appeal rights regarding the decision made on your hearing request and what you must do to have that decision reexamined. If you want this reconsideration, you may request it through any Social Security office. If additional evidence is available, you should submit it with your request. We will review the case and consider any new facts you have. A person who did not make the first decision will decide.

 (1)  case. We will correct any mistakes. We will review those parts of the decision which you believe are wrong and will look at any new facts you have. We may also review those parts which you believe are correct and may make them unfavorable or less favorable to  (2)  .

You have 60 days to ask for an appeal.

The 60 days start the day after you get this letter. We assume you got this letter 5 days after the date on it unless you show us that you did not get it within the 5-day period.

You must have a good reason for waiting more than 60 days to ask for an appeal.

You have to ask for an appeal in writing. We will ask you to sign a Form SSA-561-U2, called “Request for Reconsideration”. Contact one of our offices if you want help.

Please read the enclosed pamphlet, “Your Right to Question the Decision Made on Your Social Security Claim”. It contains more information about the appeal.

Fill-ins:

(1) “your”/name, possessive

(2) “you”/“her”/“him”

ALS070 English Translation for Spanish Cover Letter – Awards – Domestic/Foreign Address

If you do not agree with the decision, you may ask to have your case reviewed. But you must request this reconsideration from any Social Security office within 60 days from the date that you receive this notice. You can submit any additional evidence or information you feel would be helpful.

ALS072 English Translation for Spanish Cover Letter – Affirmation of Denial on Reconsideration – Domestic/Foreign Address

If you do not agree with this final decision, you can ask that your claim be reviewed by an Administrative Law Judge of the Office of Disability Adjudication and Review. But you must go to any Social Security office to request the review within 60 days from the date you receive this notice.

The enclosed pamphlet explains your right to appeal.

ALS113

If you disagree with the decisions, you have the right to appeal. A person who did not make the first decision will decide your case. We will review those parts of the decisions you disagree with and will look at any new facts you have. We may also review those parts of the case that you believe are correct and may make them unfavorable or less favorable to you.

ALS073 English Translation for Spanish Cover Letter – Affirmation of Denial on Reconsideration – Mexico Address

If you do not agree with this final decision, you can ask that your case be reviewed by an Administrative Law Judge of the Office of Disability Adjudication and Review. But you must request this review from any Social Security office within 60 days from the date you receive this notice.

ALS121

If you disagree with the nonmedical decisions we made on your case, the appeal is called a reconsideration. Some examples of nonmedical decisions are the amount of your payment, and the month your payment starts. You will not meet with the person who decides your case.

If you disagree with the disability (medical) decision made by the state, the appeal is called a hearing. Some examples of medical decisions are the date your disability started or whether you are still disabled.

ALS122

You have 60 days to ask for an appeal.

The 60 days start the day after you receive this letter. We assume you received this letter 5 days after the date on it unless you show us that you did not get it within the 5-day period.

You must have a good reason if you wait more than 60 days to ask for an appeal.

You can file an appeal with any Social Security office. You must ask for an appeal in writing. Please use our “Request for Reconsideration” form SSA-561-U2, or “Request for Hearing” form HA-501. You may go to our website at  (1)  to find the forms. You can also call, write, or visit us to request the forms. If you need help to fill out the forms, we can help you by phone or in person.

ALS123

If you ask for both a reconsideration and a hearing, we will process the hearing first, even if you made the reconsideration request first. When we make our decisions, we will send you letters explaining our decisions on both the reconsideration and the hearing.

ALS125

After we send your case for a hearing, an Administrative Law Judge (ALJ) will mail you a letter at least 20 days before the hearing to tell you its date, time and place. The letter will explain the law in your case and tell you what has to be decided. Since the ALJ will review all the facts in your case, it is important that you give us any new facts as soon as you can.

The hearing is your chance to tell the ALJ why you disagree with the decisions in your case. You can give the ALJ new evidence and bring people to testify for you. The ALJ also can require people to bring important papers to your hearing and give facts about your case. You can question these people at your hearing.

ALSR01 Hearings Level Decision by Someone Other Than an ALJ

We previously informed you of your appeal rights concerning the administrative law judge's (ALJ) decision. We also informed you of what you must do to have that decision reviewed.

If you believe that we decided any other part of  (1)  case incorrectly, you may request reconsideration on that part of  (2)  case. We will review  (3)  case and look at any new facts you have. A person who did not make the first decision will decide  (4)  case. We will review the parts of the decision that you think are wrong and correct any mistakes. We may also review the parts of our decision that you think are right. We will make a decision that may or may not be in  (5)  favor.

You have 60 days to ask for an appeal.

The 60 days start the day after you receive this letter. We assume you received this letter 5 days after the date on it unless you show us that you did not receive it within the 5-day period.

You must have a good reason if you wait more than 60 days to ask for an appeal.

You can file an appeal with any Social Security office. You must ask for an appeal in writing. Please use our “Request for Reconsideration” form, SSA-561-U2. You may go to our website at  (6)  to find the form. You can also call, write, or visit us to request the form. If you need help to fill out the form, we can help you by phone or in person.

Fill-ins:

(1) “your”/”his”/”her”

(2) “your”/”his”/”her”

(3) “your”/name, possessive

(4) “your”/”his”/”her”

(5) “your”/”his”/”her”

(6) www.socialsecurity.gov/online

APPC01 Caption

New Application

APP001 New Application

You have the right to file a new application at any time, but filing a new application is not the same thing as appealing this decision. If you disagree with this decision and you file a new application instead of appealing:

you might lose some benefits, or not qualify for any benefits, and

we could deny the new application using this decision, if the facts and issues are the same.

So, if you disagree with this decision, you should file an appeal within 60 days.

ATYC01 Caption

Information About  (1)  Fees

Fill-in:

(1) “Lawyer's”/“Representative's”

ATYC02 Caption

How To Ask Us To Review the  (1) 

Fill-in:

(1) “Determination On The Fee Amount”/“Determination On The Fee Agreement”

ATYC03 Caption

Information About Past-Due Benefits Withheld To Pay A Lawyer

ATY052 Attorney or Eligible Representative Not Registered with SSA

We withhold past-due benefits if the representative is a  (1)  and registers with us to receive direct fee payment. Although your representative is a  (2)  , he or she did not register for direct payment before we completed our work on your claim. For that reason, we did not withhold from your past-due benefits to pay the fee we approve. Therefore, the Social Security Administration is not involved in paying the fee. This is a matter between  (3)  and the  (4)  .

Fill-ins:

(1) lawyer/participant in the non-attorney direct payment demonstration project

(2) lawyer/participant in the demonstration project

(3) first and last name of number holder/you

(4) “lawyer”/“representative”

ATYR01 Attorney Fee Withheld and Paid to Lawyer

We took  (1)  out of  (2)  first check. We are paying this money to the lawyer who helped with this Social Security claim.

Fill-ins:

(1) attorney fee amount *

(2) SN

(*) indicates that the fill-in is manual

ATYR02 Fee Amount Unknown – Past-Due Benefits Unknown

We base the amount of  (1)  fee on past-due benefits, if any. As soon as we  (2)  determine the amount of benefits, we will tell you the amount of the fee  (3)  can charge.

Fill-ins:

(1) “your attorney's”/“your representative's”/“the attorney's”/“the representative's”

(2) “make a decision on your spouse's/family's/child's/children's/null claim” *

(3) “your attorney”/“your representative”/“the attorney”/“the representative”

(*) indicates that the fill-ins are manual

ATY002 Attorney Involved - Petition

When a lawyer wants to charge for helping with a Social Security claim, we must first approve the fee. We usually withhold 25 percent of past due benefits in order to pay for approved lawyer's fee.

ATYR03 Fee Agreement Subsequently Disapproved and No Past Due Benefits are Available

We wrote you before and said we had approved the fee agreement between  (1)  and the  (2)  . We also said we would tell  (3)  and the  (4)  the amount of the fee he or she can charge  (5)  .

We base the fee amount we allow under a fee agreement on  (6)  past-due benefits. There are no past-due benefits. Therefore, we no longer approve the fee agreement between  (7)  and the  (8)  .

Even though we no longer approve the fee agreement, the  (9)  can still charge a fee for his or her services. If the  (10)  wants to charge a fee, he or she must ask us in writing to approve the fee. The  (11)  must give  (12)  a copy of his or her fee request and each attachment to the request. If the  (13)  does not want to charge a fee, he or she should tell us.

Fill-ins:

(1) Manual fill-in 1 input name of beneficiary who actually hired the attorney or representative*

(2) “lawyer”/“representative”

(3) Ms. plus BLN/Mr. plus BLN/BGN/BGN plus BLN/“you”

(4) “lawyer”/“representative”

(5) Ms. plus BLN/Mr plus BLN/BGN/BGN plus BLN

(6) “her”/ “his”/ “your”

(7) Manual fill-in 2 input name of beneficiary who actually hired the attorney or representative*

(8) “lawyer”/“representative”

(9) “lawyer”/“representative”

(10) “lawyer”/“representative”

(11) “lawyer”/“representative”

(12) “her”/ “him”/ “you”

(13) “lawyer”/“representative”

(*) indicates that the fill-in is manual

ATY003 Attorney Fees Withheld - Petition

Because a lawyer  (1)  with this claim, we withheld  (2)  from  (3)   (4)  check.

Fill-ins:

(1) “helped”/“may have helped”

(2) amount withheld

(3) “your”/“her”/“his”

(4) “first”

ATYR04 Notify a Beneficiary with a Lawyer or Representative Eligible for Direct Payment that Fee Authorization Cannot Be Released at the Time of Effectuation. (Additional Information Pending)

When a  (1)  wants to charge for helping with a Social Security claim, we must approve the fee. We usually withhold 25 percent of past-due benefits in order to pay the approved  (2)  fee. We withheld $  (3)  from  (4)  in case we need to pay  (5)   (6)  .

We cannot tell you how much the  (7)  can charge at this time. When processing  (8)  claim we found we needed more information. To decide how much  (9)  benefits will be for  (10)  , we need  (11)   (12)   (13)  . When we get that information, we will decide the amount of  (14)  past-due benefits and send another letter telling you how much the  (15)  can charge. You can help us finish the work on  (16)  claim by taking the information to any Social Security office.

Fill-ins:

(1) “representative”

(2) “representative's”

(3) show the total fee amount withheld from all PICs/Show the single PICs fee amount withheld

(4) “the benefits due you and your family”/”your benefits”

(5) always use “the”

(6) “representative”

(7) “representative”

(8) Ms. plus BLN (possessive)/ Mr. plus BLN (possessive)/” your”

(9) “her”/“his”/“your”

(10) Month YYYY/Month YYYY and Month YYYY/Month YYYY through Month YYYY

(11) Manual fill-in 1 which can include choices A or B

A. proof of

B. more information about

(12) “her”/“his”/“your”

(13) Manual fill-in 2 which can include choices of workers' compensation benefits/public disability benefits/workers' compensation and public disability benefits/military service/date of birth/or free format reason*

(14) “her”/“his”/“your”

(15) “representative”

(16) “her”/“his”/“your”

(*) indicates that the fill-in is manual

ATY004 Fee Petition not Received/Approved and Direct Payment Not Waived

We generally must approve any fee  (1)  representative wants to charge for helping with  (2)  Social Security claim. The representative should send us a fee request when he or she has finished all work on the claim. If the representative will not charge a fee, he or she must tell us by sending a signed and dated statement.

Fill-ins:

(1) “your”/name, possessive

(2) “your”/”his”/”her”

ATYR05 Fee Agreement Amount - Auxiliary

 (1)  past-due benefits are  (2)  for  (3)  . Under the fee agreement between  (4)  and the  (5)  , the  (6)  cannot charge more than  (7)  for his or her work.

Fill-ins:

(1) FN possessive

(2) amount

(3) month and year/month and year through month and year

(4) person that signs the fee agreement*

(5) “lawyer”/“representative”

(6) “lawyer”/“representative”

(7) money amount *

(*) indicates that the fill-ins are manual

ATY005 Attorney Fees Withheld - Petition

When the amount of the fee is decided, we will pay the lawyer from the benefits we withheld.

ATY006 Attorney Fees Withheld - Petition

If the approved fee is more than the money we have withheld, the Social Security Administration is not involved in paying the rest of the fee.

ATYR06 Notify a Beneficiary with Representative that Fee Authorization Cannot be Released at Time of Effectuation. (WC/PDB Decision or Appeal of a Denied WC/PDB Claim is Pending)

When a representative wants to charge for helping with a Social Security claim, we must approve the fee.

We cannot tell you how much the representative can charge at this time. When processing  (1)  claim we found we needed more information. To decide how much  (2)  benefits will be for  (3)  , we need  (4)   (5)   (6)  . When we get that information, we will decide the amount of  (7)  past-due benefits and send another letter telling you how much the representative can charge. You can help us finish the work on  (8)  claim by taking the information to any Social Security office.

Fill-ins:

(1) Ms. plus BLN (possessive)/ Mr. plus BLN (possessive)/ “your”

(2) “her”/“his”/“your”

(3) Month YYYY/Month YYYY and Month YYYY/Month YYYY through Month YYYY

(4) Manual fill-in 1 which can include choices A or B

A. proof of

B. more information about

(5) “her”/“his”/”your”

(6) Manual fill-in 2 which can include choices of workers' compensation benefits/public disability benefits/workers' compensation and public disability benefits/military service/date of birth/or free format reason*

(7) “her”/“his”/“your”

(8) “her”/“his”/“your”

(*) indicates that the fill-in is manual

ATY007 Fee Withholding Information - Petition

If the approved fee is less than the money we have withheld, we will send  (1)   (2)  .

Fill-ins:

(1) SN

(2) “the rest of the money”

ATY008 Attorney Appointment Questionable Award

We need more information to decide whether a lawyer represents  (1)  in  (2)  claim for Social Security benefits. We will contact you for this information.

Fill-ins:

(1) SN

(2) “your”/“her”/“his”

ATY009 Attorney Representation Questionable

We need more information to decide whether a lawyer represents  (1)  After we decide this, we will let you know if  (2)   (3)  due any of the money we have withheld.

Fill-ins:

(1) Beneficiary's full name

(2) SN

(3) “is”/“are”

ATY010 Non-Attorney Representative, Fee Not Waived, Award

Your representative must receive approval from the Social Security Administration before a fee can be charged. If the representative wants to charge a fee, a request for approval must be sent to us as soon as all work for  (1)  is finished. If no fee will be charged, we should also be told right away.

Fill-in:

(1) SN

ATY011 Address for Sending Fee Petition

Any request for fee approval should be sent to:  (1) 

Fill-in:

(1) Address to which petition is sent

ATY012 Attorney Waived Option to Direct Payment

However, the lawyer has asked us to send all past due benefits to  (1)  .

Fill-in:

(1) “you”/“her”/“him”

ATYR12 Explanation of Withholding - Auxiliary

Because of the law, we usually withhold 25 percent of the total past-due benefits to pay an approved lawyer's fee. We withheld $  (1)  from  (2)  past-due benefits to pay  (3)  lawyer.

Fill-ins:

(1) money amount

(2) “your”/name, possessive

(3) “the”

ATY013 Attorney has not Waived Fee, No Past Due Benefits

However, there are no past due benefits available to be paid to the lawyer.

ATY014 Attorney Waived Fee, Award

However, the lawyer has told us that no fee will be charged for services on this Social Security claim. For this reason, no past due benefits have been withheld to pay the lawyer.

ATYR15 Disapproval of Fee Agreement

We cannot approve the fee agreement between you and your  (1)  because  (2)  . Even though we cannot approve the fee agreement, your  (3)  can still charge you a fee for his or her services. If your  (4)  wants to charge a fee, he or she must ask us in writing to approve the amount of the fee. Your  (5)  must give you a copy of his or her fee request and each attachment to the request. If your  (6)  does not want to charge a fee, he or she should tell us.

Fill-ins:

(1) “lawyer”/“representative”

(2) Manual fill-in 1, choice of A through I:

(A) we did not get a written agreement before we decided your claim.

(B) both you and your (representative/lawyer) did not sign the agreement.

(C) it sets a fee amount that is more than 25 percent of past-due benefits or $6000.00.

(D) there are no past-due benefits. We base the fee amount we allow under a fee agreement on your past-due benefits. Since we do not owe you any past-due benefits, we cannot approve the fee agreement.

(E) you appointed more than one representative from a law firm or other business, and all representatives did not sign a single fee agreement (unless the representative(s) who did not sign waived any fee in your case).

(F) you appointed representatives who are not members of the same law firm or other business (unless the representative(s) from the other law firm or business waived any fee in your case).

(G) you discharged a representative, or a representative withdrew from the case, before we favorably decided the claim unless the former representative waived any fee in your case).

(H) your representative died before we issued the favorable decision.

(I) you were declared legally incompetent by a State court and your guardian did not sign the fee agreement.*

(3) “lawyer”/“representative”

(4) “lawyer”/“representative”

(5) “lawyer”/“representative”

(6) “lawyer”/“representative”

(*) indicates that the fill-in is manual

ATY016 Explanation of Attorney Fee Assessment (With Cap)

We are paying the  (1)  from the benefits we withheld. Therefore, we must collect a service charge from him or her. The service charge is 6.3 percent of the fee amount we pay, but not more than $93, which is the most we can collect in each case under the law. We will subtract the service charge from the amount payable to the  (2)  .  (3) 

The  (4)  cannot ask you to pay for the service charge. If the  (5)  disagrees with the amount of the service charge, he or she must write to the address shown at the top of this letter. The  (6)  must tell us why he or she disagrees within 15 days from the day he or she gets this letter.

Fill-ins:

(1) “representative”

(2) “representative”

(3) After we subtract the amount we are paying towards the fee, we will send you the balance of the amount we withheld/NULL

(4) “representative”

(5) “representative”

(6) “representative”

ATY018 Non-Attorney Representative, Fee Waived, Award

Your representative told us that a fee will not be charged. If a fee is charged, your representative must receive approval from the Social Security Administration.

ATYR20 Fee Amount – Number Holder Only – Delayed Auxiliary Claims Pending or Expected

We base the amount of the  (1)  fee on the total past-due benefits for you and your family. Your past-due benefits are

$  (2)  for  (3)  . Under the fee agreement, the  (4)  can charge you $  (5)  for his or her work. As soon as we make a decision on your family's claim(s) and decide the amount of their past-due benefits, we will tell them if the  (6)  can charge an additional fee. We also will say how much that fee amount will be.

The amount of the fee for your and your family's claim(s) does not include any out-of-pocket expenses (for example, costs to get copies of doctors' or hospitals' reports). This is a matter between you and the  (7)  .

Fill-ins:

(1) “lawyer's”/“representative's”

(2) Show amount of the N/H's past-due benefits in format “$$$$.¢¢”

(3) MM/YYYY or MM/YYYY through MM/YYYY

(4) “lawyer”/“representative”

(5) Show amount of the fee in $$$$.¢¢ format.

(6) “lawyer”/“representative”

(7) “lawyer”/“representative”

ATYR22 Fee Amount – Number Holder and Non-Delayed Auxiliary Beneficiary(ies) – Delayed Auxiliary Claims Pending or Expected

We base the amount of the  (1)  fee on the total past-due benefits for you and your family. Your past-due benefits are $  (2)  for  (3)  .  (4)  past-due benefits are $  (5)  for  (6)  . Under the fee agreement, the  (7)  can charge you and  (8)  $  (9)  for his or her work. As soon as we make a decision on your  (10)  and decide the amount of the past-due benefits, we will tell  (11)  if the  (12)  can charge an additional fee. We also will say how much that fee amount will be.

The amount of the fee for your and your family's claim(s) does not include any out-of-pocket expenses (for example, costs to get copies of doctors' or hospitals' reports). This is a matter between you and the  (13)  .

Fill-ins:

(1)

Choice 1 - lawyer's

Choice 2 - representative's

(2) The amount of the N/H's past-due benefits in $$$$.¢¢ format.

(3)

Choice 1 - MM/YYYY

Choice 2 - MM/YYYY through MM/YYYY

(4)

Choice 1 - (current action involves only one auxiliary beneficiary) - insert possessive case of name of auxiliary beneficiary, in the format First Name, Last Name. Example: Henry James.

Choice 2 - (current action involves two or more auxiliary beneficiaries) - insert possessive case of names of auxiliary beneficiaries, in the format First Name, Last Name, (separated by commas and/or “and,” as appropriate). Example: Henry James, William Jones, and Alice James. *

(5) The amount of the non-delayed auxiliary beneficiary's (ies') past-due benefits *

(6)

Choice 1 – MM/YYYY

Choice 2 - MM/YYYY through MM/YYYY

(7)

Choice 1 - lawyer

Choice 2 - representative

(8)

Choice 1 - (current action involves only one auxiliary beneficiary) - insert name of auxiliary beneficiary, in the format First Name, Last Name. Example: Henry James.

Choice 2 - (current action involves two or more auxiliary beneficiaries) - insert names of auxiliary beneficiaries, in the format First Name, Last Name, (separated by commas and/or “and,” as appropriate). Example: Henry James, William James, and Alice James. *

(9) The amount of the fee based on total past-due benefits for the N/H's claim and any non-delayed auxiliary claims *

(10)

Choice 1 - spouse's claim

Choice 2 - other child's claim

Choice 3 - other children's claims

Choice 4 - spouse's and other child's claims

Choice 5 - spouse's and other children's claims *

(11)

Choice 1 - him

Choice 2 - her

Choice 3 - them *

(12)

Choice 1 - lawyer

Choice 2 - representative

(13)

Choice 1 - lawyer

Choice 2 - representative

(*) indicates that the fill-ins are manual

ATY023 Auxiliary's Past-Due Benefit (s) Withheld – SSI Pending

We also withheld  (1)  from  (2)  family's past-due benefits.

Fill-ins:

(1) legal payment deduction amount

(2) “your”/“her”/“his”

ATY079 Claim is Denied and No Fee Agreement Type is Present

 (1)   (2)  must ask us for approval before charging a fee. If  (3)   (4)  wants to charge a fee, a request for approval must be sent to us as soon as all work on this case for  (5)   (6)  is finished.

Fill-ins:

(1) SN possessive

(2) “lawyer”/“representative”

(3) SN possessive

(4) “lawyer”/“representative”

(5) SN

(6) null

ATY080 Attorney/Non-Attorney Representation Questionable, Disallowance

An attorney or other representative must ask us for approval before charging a fee. If  (1)  a representative who wants to charge a fee, a request for approval must be sent to us as soon as all work on this case is finished. If no fee will be charged, we should also be told right away. If the fee is approved, the Social Security Administration will not be involved in paying the fee.

Fill-in:

(1) “you have”/“she has”/“he has”

ATY081 Non-Attorney/Attorney Fee Waived, Disallowance

 (1)  has told us that a fee will not be charged for helping  (2)   (3)  with  (4)  claim.

Fill-ins:

(1) attorney name/representative name

(2) SN

(3)

“and [3a] family members”/null

[3a] “your”/“her”/“his”

ATY800 Fee Agreement Approval – Number Holder

We have approved the fee agreement between you and your  (1)  .

Fill-in:

(1) “lawyer”/“representative”

ATY801 Fee Agreement Approval - Auxiliary

When  (1)  filed  (2)  claim for benefits,  (3)  used a  (4)  to help with the claim. We have approved a fee agreement between  (5)  and  (6)   (7)  . The  (8)  work involved the benefits of everyone on the record.

Fill-ins:

(1) beneficiary name

(2) “your”/“her”/“his”

(3) “you”/“she”/“he”

(4) “lawyer”/“representative”

(5) beneficiary name

(6) “the”

(7) “lawyer”/“representative”

(8) “lawyer's”/“representative's”

ATY804 Fee Agreement Amount – Number Holder

 (1)  past-due benefits are  (2)  for  (3)  . Under the fee agreement, the  (4)  cannot charge you more than  (5)  for his or her work. The amount of the fee does not include any out-of-pocket expenses (for example, costs to get copies of doctors or hospitals reports). This is a matter between you and your  (6)  .

Fill-ins:

(1) “Your”/FN possessive

(2) money amount

(3) month and year/month and year through month and year

(4) “lawyer”/“representative”

(5) pending fee amount

(6) “lawyer”/“representative”

ATY808 Procedure for Review of Fee Under Fee Agreement – Number Holder

You, the  (1)  or the person who decided your case can ask us to review the amount of the fee we say the  (2)  can charge.  (3) 

If you think the amount of the fee is too high, write us within 15 days from the day you get this letter. Tell us that you disagree with the amount of the fee and give your reasons. Send your request to this address:

Social Security Administration
Office of Disability Adjudication and Review
Attorney Fee Branch
5107 Leesburg PikeFalls Church, Virginia 22041-3255

The  (4)  also has 15 days to write us if he or she thinks the amount of fee is too low.  (5) 

If we do not hear from you or the  (6)  , we will assume you both agree with the amount of the fee shown.

Fill-ins:

(1) “lawyer”/“representative”

(2) “lawyer”/“representative”

(3) “Your family members who have filed claims on your Social Security number (SSN) also may ask us to review the amount of the fee.”/null

(4) “lawyer”/“representative”

(5) “null”

(6) “lawyer”/“representative”

ATY809 Procedure for Review of Fee Under Fee Agreement - Auxiliary

You,  (1)  , the  (2)  or the person who decided your case can ask us to review the amount of the fee we say the  (3)  can charge.

If you think the amount of the fee is too high, write us within 15 days from the day you get this letter. Tell us that you disagree with the amount of the fee and give your reasons. Send your request to this address:

Social Security Administration
Office of Disability Adjudication and Review
Attorney Fee Branch
5107 Leesburg Pike
Falls Church, Virginia 22041-3255

The  (4)  also has 15 days to write us if he or she thinks the amount of fee is too low.  (5) 

If we do not hear from you or the  (6)  , we will assume you both agree with the amount of the fee shown.

Fill-ins:

(1) Beneficiary name

(2) “lawyer”/“representative”

(3) “lawyer”/“representative”

(4) “lawyer”/“representative”

(5) “If we withheld past-due benefits to pay your lawyer's fee, we will

not pay the fee until 15 days pass and no one asks us to review the

amount of the fee.”/null

(6) “lawyer”/“representative”

ATY816 Attorney Responsibilities – Fee Agreement Disapproved

If your lawyer wants us to pay the fee from your withheld benefits, he or she must ask us to approve the fee within 60 days of the date of this letter.

If your lawyer:

Is finished working on this case and wants to charge a fee, he or she should ask us to approve the amount of the fee right away.

Is not finished working on this case and wants to charge a fee, he or she must tell us within 60 days of the date of this letter that he or she will ask for a fee.

Does not want to charge a fee or does not want us to pay the fee from the benefits we withheld, he or she should tell us right away.

ATY817 Review of Determination on Fee Agreement

You or the  (1)  can ask us to review the determination on the fee agreement. If you decide to ask us for a review, write us within 15 days from the day you get this letter. Tell us that you disagree and give your reasons. Send your request to this address:

Social Security Administration
Office of Disability Adjudication and Review
Attorney Fee Branch
5107 Leesburg Pike
Falls Church, Virginia 22041-3255

The  (2)  also has 15 days to write us if he or she does not agree with the determination on the fee agreement.

Fill-ins:

(1) “lawyer”/“representative”

(2) “lawyer”/“representative”

ATY825 Fee Agreement Amount – Concurrent Title II/Title XVI – Additional Fee for Title XVI Claim – Number Holders Only

If we approve your claim for SSI, the  (1)  may be able to charge an additional amount for his or her work. We will send you another letter about SSI telling you the additional amount of the fee, if any, he or she can charge.

Fill-ins:

(1) “lawyer”/“representative”

ATY834 Fee Agreement Amount – Number Holder and Family

 (1)  past-due benefits are  (2)  for  (3)  .  (4)  family's past-due benefits are  (5)  for  (6)  . Under the fee agreement, the  (7)  cannot charge  (8)  and  (9)  family more than  (10)  for his or her work. The amount of the fee does not include any out-of-pocket expenses (for example, costs to get copies of doctors' or hospitals' reports). This is a matter between you and the  (11)  .

Fill-ins:

(1) “Your”/FN possessive

(2) money amount

(3) month and year/month and year through month and year

(4) “your”/“her”/“his”

(5) money amount

(6) month and year/month and year through month and year

(7) “lawyer”/“representative”

(8) “you”/SN

(9) “your”/“her”/“his”

(10) the total fee amount

(11) “lawyer”/“representative”

ATY836 Explanation of Withholding – Fee Agreement – Amount Withheld Greater than Fee Amount – SSI Pending – Number Holder

Based on the law, we must withhold part of past-due benefits to pay an appointed representative. We cannot withhold more than 25 percent of past-due benefits to pay an authorized fee. We withheld  (1)  from  (2)  past-due benefits to pay  (3)  representative.

Fill-ins:

(1) money amount

(2) “Mr.” plus BLN possessive/“Ms.” plus BLN possessive/null plus BGN possessive/null plus FN possessive/“your”

(3) “the”

ATY838 Explanation of Withholding – Fee Agreement – Amount Withheld Greater than Fee Amount – SSI Pending – Number Holder's Family

Because of the law, we usually withhold 25 percent of the total past-due benefits to pay an approved lawyer's fee. We withheld  (1)  from  (2)  past-due benefits to pay  (3)  lawyer. We also withheld  (4)  from  (5)  family's past-due benefits. We base the amount of the fee  (6)  lawyer can charge on the total past-due benefits due  (7)  and  (8)  family.

Fill-ins:

(1) money amount

(2) “your”/name, possessive

(3) “the”

(4) money amount

(5) “your”/“her”/“his”

(6) “the”

(7) “you”/name

(8) “your”/“her”/“his”

BEN030 MBA Chart – Shows Changes to MBA on All DIB Awards and RR Certification Awards

The following chart shows  (1)  benefit amount(s) before any deductions or rounding. The amount  (2)  actually receive(s) may differ from  (3)  full benefit amount. When we figure how much to pay  (4)  , we must deduct certain amounts, such as Medicare premiums. We must also round down to the nearest dollar.

Beginning Date

Benefit Amount

Reason

 (5)   (6) 

 (7) 

 (8) 

 (9)  (10)

(11)

(12)

(13)(14)

(15)

(16)

(17)(18)

(19)

(20)

(21)(22)

(23)

(24)

(25)(26)

(27)

(28)

(29)(30)

(31)

(32)

(33)(34)

(35)

(36)

(37)(38)

(39)

(40)

(41)(42)

(43)

(44)

(45)(46)

(47)

(48)

(49)(50)

(51)

(52)

(53)(54)

(55)

(56)

(57)(58)

(59)

(60)

(61)(62)

(63)

(64)

(65)(66)

(67)

(68)

Fill-ins:

(1) your/beneficiary's given name plus “beneficiary's last name possessive

(2) “you”/“she”/ “he”

(3) “your”/“her”/“his”

(4) “you”/“her”/“him”

(6) EFD year associated with fill-in 5, in the format YYYY

(7) MBA amount, corresponding to EFD from fill-in 5

(8) Entitlement began/Cost-of-living adjustment/Benefits to another person began or ended/Credit for additional earnings

Fill-ins (9) through (68) follow the logic of fill-ins (5) through (8)

BEN031 DIB Over RIB Entitlement

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

Fill-ins:

(1) you are/Ms. plus beneficiary's last name plus “is”/Mr. plus beneficiary's last name plus “is”

(2) “your”/“her”/“his”

BEN032 DIB Over RIB Entitlement/Dual Entitlement Involving an Adjustment in Retroactive Benefits

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

Fill-ins:

(1) your/beneficiary's given name/beneficiary's given name plus beneficiary's last name, possessive/Ms. plus beneficiary's last name, possessive/Mr. plus beneficiary's last name, possessive

(2) “first”/”next”

(3) “you”/“she”/“he”

BEN051 Dual Entitlement Benefits Combined in One Check

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

Fill-ins:

(1) “you”/“her”/“him”

(2) “your”/”her”/”his”

BEN052 Benefits Paid in Separate Check

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

Fill-in:

(1) “you”/“her”/“him”

BEN053 Auxiliary Benefits Reduced by Primary 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-ins:

(1) “your”/“her”/“his”

(2) type of benefit

(3) “you are”/“she is”/“he is”

(4) “your”/“her”/“his”

(5) “your”/“her”/“his”

(6) Money fill-in

(7) type of benefit

(8) Money fill-in

(9) “your”/“her”/“his”

BRR004 RSI Responsibilities Information

 (1)  benefits are based on the information  (2)  gave us. If this information changes, it could affect  (3)  benefits. For this reason, it is important that you report changes to us right away.

We have enclosed a pamphlet,  (4)  . It tells you what must be reported and how to report.  (5) 

Fill-ins:

(1) “Ms.” plus BLN possessive/”Mr.” plus BLN possessive/null plus BGN possessive/null plus FN possessive/“Your”

(2) “she”/“he”/“you”

(3) “her”/“his”/“your”

(4) “Your Payments While You are Outside the United States” (Pub #05-10137)/ “What You Need To Know When You Get Retirement Or Survivors Benefits: (Pub #05-10077)

(5) null

BRR005 Student Responsibilities Information

Please let us know right away if  (1)  no longer a full-time student at an elementary or secondary level school.

Fill-ins:

(1) “you are”/“she is”/“he is”

BRR006 Closed Period

If  (1)  health gets worse and you think  (2)  disabled before  (3)  full retirement age,  (4)   (5)   (6)   (7)  , you should contact us about applying again for disability benefits. Also, please get in touch with us three months before  (8)  age 62 to find out whether  (9)  for retirement benefits.

Fill-ins:

(1) Ms. plus beneficiary's last name, possessive/Mr. plus beneficiary's last name, possessive/your

(2) “you are”/“she is”/“he is”

(3) “you reach/she reaches/he reaches”

(4) full retirement age, in the format “65”

(5) and/NULL

(6) additional FRA months/NULL

(7) months/NULL

(8) “you reach/she reaches/he reaches”

(9) “you qualify/she qualifies/he qualifies”

BRR008 Representative Payee Appointed

As a representative payee, you have additional responsibilities. They are discussed in the enclosed pamphlet, “A Guide for Representative Payees.”

If you have any questions related to your duties as a representative payee, we invite you to visit our website at  (1)  on the internet.

BRR010 Government Pension Responsibilities

If the amount of  (1)  government pension changes, it may affect  (2)  Social Security benefit. Please let us know about any change right away.

Fill-ins:

(1) “your”/“her”/“his”

(2) “your”/“her”/“his”

BRRR13 SEI Used, Return Not Yet Filed

 (1)  benefits are partly based on self-employment income for  (2)  . As soon as the taxable year is over,  (3)  should report this income on a federal tax return.

Then, you must send us a copy of the return. Also, send us a cancelled check or other proof to show that  (4)  filed the return. Otherwise, we will stop  (5)  benefits and ask you to return any money we have sent you.

Fill-ins:

(1) “your”/“her”/“his”

(2) year *

(3) “you”/“she”/“he”

(4) “you”/“she”/“he”

(5) “your”/“her”/”his”

(*) indicates that the fill-ins are manual

BRR014 RRB Earnings Included

We used  (1)  past railroad work to figure  (2)  Social Security benefit. If  (3)  for the railroad again, please tell us right away if:

 (4)  total railroad work adds up to 120 months, or

 (5)  for the railroad 60 months after 1995.

Fill-ins:

(1) name, possessive/“your”

(2) “your”/“his”/“her”

(3) “you work”/“he works”/“she works”

(4) “Your”/”His”/”Her”

(5) “You work”/“He works”/“She works”

BRR016 Reporting Responsibilities to RRB

The decisions we made on your claim are based on information you gave us. If this information changes, it could affect your benefits. For this reason, it is important that you report changes to us or to the Railroad Retirement Board right away. We have enclosed a pamphlet which tells you what must be reported and how to report.

BRR040 Reporting Responsibilities - General

Please let us know if any of the following things happens:

The amount of money  (1)   (2)  to make, changes; or

Another family member starts working; or

A family member moves out of the household.

The way we pay benefits could change if any of these things happens.

Fill-ins:

(1) “you”/“she”/“he”

(2) “expect”/“expects”

BRR055 DWB Closed Period

If  (1)  health gets worse and you think  (2)  disabled before  (3)  age 60, you should contact us about applying again for disability benefits.

Fill-ins:

(1) FN possessive

(2) “you were”/“she was”/“he was”

(3) “you reach”/“she reaches”/“he reaches”

BRR057 Number Holder Age 55 to Within 4 Months of Age 62, MOE After 6/80 Based on Onset After 1978 – Auxiliary Benefits Reduced Due to DIB Family Maximum

You should get in touch with us about 3 months before  (1)   (2)  age 62. At that time, you can find out whether  (3)  family would receive higher benefits if  (4)  for retirement benefits.

Fill-ins:

(1) FN

(2) “reach”/“reaches”

(3) “your”/“her”/“his”

(4) “you file”/“she files”/“he files”

BRR059 Rights and Responsibilities of People Receiving DIB Benefits

We based our decision on information you gave us. If this information changes, it could affect  (1)  benefits. For this reason, it is important that you report changes to us right away.

We have enclosed a pamphlet, “What You Need To Know When You Get Social Security Disability Benefits.” It tells you what you must report and how to report. Please be sure to read the parts of the pamphlet that tell you what to do if  (2)  to work or if  (3)  health improves.

Fill-ins:

(1) “your”/“his”/“her”

(2) “you go”/“he goes”/“she goes”

(3) “your”/“his”/“her”

BRR060 Medical Improvement – Mother's/Father's Benefits – Rights and Responsibilities

The decisions we made on your claim are based on information you gave us. If this information changes, it could affect your benefits. For this reason, it is important that you report changes right away. We have enclosed a pamphlet, “When You Get Social Security Disability Benefits...What You Need To Know.” It will tell you what must be reported and how to report. Be sure to read the parts of the pamphlet about what to do if your child goes to work or if your child's health improves. Also, remember to tell us if your child is no longer in your care.

CDR001 Medical Improvement Possible

Doctors and other trained staff decided that  (1)   (2)  disabled under our rules. But, this decision must be reviewed at least once every 3 years. We will send you a letter before we start the review. Based on that review,  (3)  benefits will continue if  (4)  still disabled, but will end if  (5)  no longer disabled.

Fill-ins:

(1) FN

(2) “are”/“is”

(3) “your”/“her”/“his”

(4) “you are”/“she is”/“he is”

(5) “you are”/“she is”/“he is”

CDR002 Medical Improvement Not Expected

Doctors and other trained staff decided that  (1)   (2)  disabled under our rules. However, we must review all disability cases. Therefore, we will review  (3)  case in 5 to 7 years. We will send you a letter before we start the review. Based on that review,  (4)  benefits will continue if  (5)  still disabled, but will end if  (6)  no longer disabled.

Fill-ins:

(1) FN

(2) “are”/“is”

(3) “your”/”her”/“his”

(4) “your”/“her”/“his”

(5) “you are”/“she is”/“he is”

(6) “you are”/“she is”/“he is”

CDR003 Medical Improvement Expected

The doctors and other trained personnel who decided that  (1)  disabled expect  (2)  health to improve. Therefore, we will review  (3)  case in  (4)  . We will send you a letter before we start the review. Based on that review,  (5)  benefits will continue if  (6)  still disabled, but will end if  (7)  no longer disabled.

Fill-ins:

(1) FN “are”/“is”

(2) “your”/“her”/“his”

(3) “your”/“her”/“his”

(4) month and year

(5) “your”/“her”/“his”

(6) “you are”/“she is”/“he is”

(7) “you are”/“she is”/“he is”

CDR024

We decided that  (1)  disabled under our rules. But, this decision must be reviewed once every 3 years. We will send you a letter before we start the review. Based on that review,  (2)  benefits will continue if  (3)  still disabled, but will end if  (4)  no longer disabled.

Fill-ins:

(1) “she is”/“he is”/ “you are”

(2) “her”/“his”/ “your”

(3) “she is”/“he is”/“you are”

(4) “she is”/“he is”/“you are”

CDR025

We decided that  (1)  disabled under our rules. However, we must review all disability cases. Therefore, we will review  (2)  case in 5 to 7 years. We will send you a letter before we start the review. Based on that review,  (3)  benefits will continue if  (4)  still disabled, but will end if  (5)  no longer disabled.

Fill-ins:

(1) “she is”/ “he is”/“you are””

(2) “her”/“his”/ “your”

(3) “her”/“his”/ “your”

(4) “she is”/“he is”/ “you are””

(5) “she is”/“he is”/ “you are”

CDR026

Because we expect  (1)  health to improve, we will review  (2)  case in  (3)  . We will send you a letter before we start the review. Based on that review,  (4)  benefits will continue if

 (5)  still disabled, but will end if  (6)  no longer disabled.

Fill-ins:

(1) “her”/“his”/ “your”

(2) “her”/“his”/ “your”

(3) Month YYYY

(4) “her”/“his”/“your”

(5) “she is”/“he is”/ “you are”

(6) “she is”/“he is”/ “you are”

CDR031

You are entitled to benefits because we decided that your child is disabled under our rules. But, this decision must be reviewed at least once every three years. We will send you or your child a letter before we start the review. Based on that review, your benefits will continue if your child is still disabled, but will end if our child is no longer disabled.

CDR032

You are entitled to benefits because we decided that your child is disabled under our rules. However we must review all disability cases. Therefore, we will review your child's case in 5 to 7 years. We will send you or your child a letter before we start the review. Based on that review, your benefits will continue if your child is still disabled, but will end if your child is no longer disabled.

CDR033

You are entitled to benefits because you have a disabled child in your care. We expect your child's health to improve. Therefore, we will review your child's case in  (1)  . We will send you a letter before we start the review. Based on that review, your benefits will continue if your child is still disabled, but they will end if your child is no longer disabled.

Fill-in:

(1) Month YYYY

CHKC01 Caption

Why We Cannot Pay  (1) 

Fill-in:

(1) “You”/SN

CHKC02 Caption

We Cannot Pay You For Some Months

CHKC03 Caption

Why We Are Delaying Your  (1)  Payments

Fill-in:

(1) Social Security

CHKC04 Caption

We Can Only Pay  (1)  For A Short Time

Fill-in:

(1) “You”/SN

CHKC08 Caption

Why We Cannot Pay  (1)  Beginning  (2) 

Fill-ins:

(1) “You”/SN

(2) month and year

CHKD08 Dictated Text

CHKC09 Caption

Your Benefits

CHKC11 Caption

When We Begin Your Payments

CIC001 Disallowance – No Child in Care

 (1)  not qualify for  (2)  benefits because  (3)  not caring for  (4)  and  (5)  not age  (6)  .

Fill-ins:

(1) “You do”/“She does”/ “He does”

(2) “wife's”/“husband's”/“mother's”/“father's”

(3) “you are”/“she is”/ “he is”

(4) “a child of [4a] who is entitled to Social Security benefits”/“a child who is entitled to benefits on [4b] Social Security record”/“[4c] natural or adoptive child who is entitled to benefits on [4b] Social Security record.”

[4a] NH's SN

[4b] NH's SN

[4c] “your”/“her”/“his”

(5) “you are”/“she is”/ “he is”

(6) “60”/“62”

CIC010 Disabled Minor Child Onset Established Later than Alleged – Spouse MOE Affected

We found that your child became disabled  (1)  . This is different from the date given on the application. You are entitled to benefits because you have a disabled child in

your care. Therefore, the date the child became disabled

affects when your benefits start. You are entitled to benefits beginning  (2)  .

Fill-ins:

(1) date of onset

(2) date of entitlement

CIC011 Disabled Minor Child Given a Closed Period of Disability – Spouse MOE Affected

To be entitled to Social Security Benefits, you must have a child in your care who is also entitled to benefits. And, that child must be under age 16 or disabled.

We have decided that your child became disabled according to our rules on  (1)  and was no longer disabled in  (2)  . Therefore, the first month for which we could pay you benefits is  (3)  . We could pay you for the month the disability ended and the following 2 months. This means that the last month for which you were entitled to benefits was  (4)  .

Fill-ins:

(1) date of onset

(2) ending date of disability

(3) date of entitlement

(4) ending date of entitlement

CIC012 Medical Improvement Possible – Mother's/Father's Benefits – 3 Year Diary

You are entitled to benefits because doctors and other trained staff decided that your child is disabled under our rules. But, this decision must be reviewed at least once every 3 years. We will send you or your child a letter before we start the review. Based on that review, your benefits will continue if your child is still disabled, but will end if your child is no longer disabled.

CIC013 Medical Improvement Not Expected – Mother's/Father's Benefits – 5 Year Diary

You qualify for benefits because doctors and other trained staff decided that you have a disabled child in your care. However we must review all disability cases. Therefore, we will review your child's case in 5 to 7 years. We will send you a letter before we start the review. Based on that review, your benefits will continue if your child is still disabled, but will end if your child is no longer disabled.

CIC014 Medical Improvement Expected – Mother's/Father's Benefits – 6 to 18 Month Diary

You are entitled to benefits because you have a disabled child in your care. The doctors and other trained personnel who made the disability decision expect your child's health to improve. Therefore, we will review your child's case in  (1)  . We will send you a letter before we start the review. Based on that review, your benefits will continue if your child is still disabled. But they will end if your child is no longer disabled.

Fill-in:

(1) date of review in the format Month YYYY

CIC015 Disabled Minor Child Given a Closed Period of Disability – Potential for Future Spouse's (Mother's/Father's Entitlement)

If your child's health gets worse and you think  (1)  is disabled before reaching age 22, you should contact us about applying again for benefits.

Fill-in:

(1) “he/she”

CLOC01 Caption

Other Social Security Benefits

CLOC06 Caption

Others Who May Be Eligible For Benefits

CLO001 General Closeout for Disallowances

 (1)  not due any other Social Security benefits. In the future, if you think  (2)  may qualify for benefits from us,  (3)  will need to apply again.

Fill-ins:

(1) “You are”/'He is”/”She is”

(2) “you”/“he”/“she”

(3) “you”/“he”/“she”

CLO002 General Closeout for Awards

 (1)   (2)  can receive from us at this time. In the future, if you think  (3)  might qualify for another benefit from us,  (4)  will need to apply again.

Fill-ins:

(1) “This benefit is the only benefit”/“These benefits are the only benefits”

(2) “you”/“he”/“she”

(3) “you”/“he”/“she”

(4) “you”/“he”/“she”

CLO003 Closeout for Lump Sum Awards

We checked to see if  (1)  for any other Social Security benefit on  (2)  record. We found that this is the only one  (3)  can receive from us at this time. In the future, if you think  (4)  might qualify for another benefit from us,  (5)  will need to apply again.

Fill-ins:

(1) “you qualify”/“he qualifies”/ “she qualifies”

(2) NH's FN

(3) “you”/“he”/ “she”

(4) “you”/“he”/“she”

(5) “you”/“he”/“she”

CLO036

 (1)   (2)  may now be eligible for benefits on  (3)  record.  (4)  named the following  (5)  when  (6)  applied for benefits:

Fill-ins:

(1) “Your”/Beneficiary's name (possessive)/

(2) “child”/ “children”

(3) “your”/“his”/ “her”

(4) “You”/“He”/“She”

(5) “child”/“children”

(6) “you”/“he”/ “she”

CLO037

  •  (1) 

  •  (2) 

  •  (3) 

  •  (4) 

  •  (5) 

  •  (6) 

  •  (7) 

  •  (8) 

  •  (9) 

  •  (10) 

Fill-ins:

(1) First child named on DEPC screen

(2) Second child named on DEPC screen

(3) Third child named on DEPC screen

(4) Fourth child named on DEPC screen

(5) Fifth child named on DEPC screen

(6) Sixth child named on DEPC screen

(7) Seventh child named on DEPC screen

(8) Eighth child named on DEPC screen

(9) Ninth child named on DEPC screen

(10) Tenth child named on DEPC screen

CLO038

If  (1)  not filed an application for benefits for the  (2)  , please contact us.

(1) “you have”/“he has”/”she has”

(2) “child”/ “children”

CLOR05 Award Closeout When Second Claim Pending

This  (1)  benefit is the only benefit we can pay  (2)  at this time. We will let you know if  (3)  eligible for  (4)  benefits.  (5)  cannot receive any other type of benefits based on the application  (6)  filed.

Fill-ins:

(1) type of benefit currently being awarded, e.g., retirement *

(2) “you”/“him”/“her”

(3) “you are”/“he is”/“she is”

(4) type of benefit pending, e.g., retirement *

(5) “You”/“He”/“She”

(6) “you”/“he”/“she”

(*) indicates that the fill-ins are manual

CLOR06 Award Closeout When DIB Pending

The  (1)  benefit is the only one to which  (2)   (3)  entitled, with the possible exception of a disability benefit. We will let you know as soon as we decide whether  (4)   (5)  disabled. We will send you another letter to tell you what we decide about  (6)  disability claim.

Fill-ins:

(1) type of benefit currently being awarded *

(2) “you”/SN

(3) “are”/“is”

(4) “you”/“she”/“he”

(5) “are”/“is”

(6) “your”/“her”/“his”

(*) indicates that the fill-ins are manual

CLOR07 Closeout – Other Benefit Possible

We are still looking to see if  (1)  can receive  (2)  benefits.  (3)  cannot receive any other type of benefits based on the application  (4)  filed.

Fill-ins:

(1) “you”/“he”/“she”

(2) type of benefit, e.g., retirement benefit *

(3) “You”/“He”/“She”

(4) “you”/“he”/“she”

(*) indicates that the fill-ins are manual

CLOR11 Closeout of Potential Benefit

The  (1)  benefit is the only kind of benefit  (2)   (3)  entitled to receive, with the possible exception of  (4)  benefits. You told us when you applied for  (5)  benefits  (6)   (7)  that you did not wish to apply for  (8)  benefits  (9)  at that time.

If you change your mind, you need to apply for these benefits. The application date can make a difference in the amount we pay. If you apply within 6 months of the date of this letter, we may be able to use the date of your application for  (10)  benefits as the date of your application for  (11)  benefits.

Fill-ins:

(1) type of benefit*

(2) “you”/FN

(3) “are”/“is”

(4) type of benefit *

(5) type of benefit*

(6) “for”/null

(7) SN/null

(8) type of benefit *

(9) “for him”/“for her”/null

(10) type of benefit*

(11) type of benefit *

(*) indicates that the fill-ins are manual

CLOR12 Closeout – Family Benefits Involved

The  (1)  benefit is the only kind of benefit  (2)   (3)  family are entitled to receive, with the possible exception of  (4)  benefits. You told us when you applied for  (5)  benefits  (6)   (7)  that  (8)  did not wish to apply for  (9)  benefits at that time.

If  (10)  mind,  (11)  to apply for these benefits. The application date can make a difference in the amount we pay. If  (12)  within 6 months of the date of this letter, we may be able to use the date of the application for  (13)  benefits  (14)   (15)  as the date of application for  (16)  benefits.

Fill-ins:

(1) “retirement”/“disability”

(2) “you and your family”/NHFN

(3) “and his”/“and her”/null

(4) “wife's”/“husbands”/“child's” *

(5) “retirement”/“disability”

(6) “for”/null

(7) NHSN/null

(8) “you/your wife”/“your husband”/ “your child” *

(9) “wife's”/“husband's”/“child's” *

(10) “you change your”/“your wife changes her”/“your husband changes his”/“your child changes his/her” *

(11) “you need”/“she needs”/“he needs” *

(12) “you apply”/“your wife applies”/“your husband applies”/“your child applies” *

(13) “retirement”/“disability”

(14) “for”/null

(15) NHSN/null

(16) “wife's”/“husband's”/“child's” *

(*) indicates that the fill-ins are manual

CLOR13 Lump-Sum – Closeout to Other Benefits

The lump-sum death payment is the only kind of payment  (1)   (2)  entitled to receive, with the possible exception of  (3)  benefits. You told us when you applied for the lump-sum death payment  (4)   (5)  that you did not wish to apply for  (6)  benefits  (7)  at that time.

If you change your mind, you need to apply for these benefits. The application date can make a difference in the amount we pay. If you apply within 6 months of the date of this letter, we may be able to use the date of the application for  (8)  benefits.

Fill-ins:

(1) “you”/FN

(2) “are”/“is”

(3) type of benefit *

(4) “for”/null

(5) SN/null

(6) type of benefit *

(7) “for him”/“for her”/null

(8) type of benefit *

(*) indicates that the fill-ins are manual

CLOR20 Auxiliary Claimant Not Insured On Own Record

Benefits are not payable on your own record because you have not worked long enough under Social Security. To qualify, you need credit for  (1)  calendar quarters of work. You now have  (2)  . If you earn the additional quarters, please contact any Social Security office.

Fill-ins:

(1) required QCs *

(2) acquired QCs *

(*) indicates that the fill-in is manual

COA004 Beneficiary is Living in Tax Treaty Country of Switzerland

We will deduct a 15 percent Federal income tax from  (1)  monthly benefits. This is because of a treaty with Switzerland which says we will tax Social Security benefits paid to residents of Switzerland at this rate.

Please let us know if  (2)   (3)  address again.

Fill-ins:

(1) your/beneficiary's give name/beneficiary's full name possessive/Ms. plus beneficiary's last name possessive/Mr. plus beneficiary's last name possessive

(2) “you change”/“she changes”/“he changes”

(3) “your”/“her”/“his”

COL001 Cost of Living Adjustment

We raised  (1)  monthly benefit amount beginning  (2)   (3)  because the cost of living increased.

Fill-ins:

(1) “your”/“her”/“his”

(2) date in format of December 1990

(3) and again in [3a]/null

[3a] Month YYYY/Month YYYY and Month YYYY/Month YYYY, Month YYYY and Month YYYY/Month YYYY, Month YYYY, Month YYYY and Month YYYY

COPC01 Caption

Other Information

COPD01 Dictated Text

COP001 Copy of Notice to Third Party/ALJ/Attorney or Representative

We are sending a copy of this notice to  (1)   (2)   (3)   (4)   (5)  .

Fill-ins:

(1) claimant name/null

(2) “,”/“and”/null

(3) third party name/ALJ name/null

(4) “and”/null

(5) attorney name/representative name/null

COP002 Copy Cover Notice

Enclosed is a copy of a letter we sent to  (1)  .

Fill-in:

(1) FN

CTZ005 SMI Only Disallowance

 (1)  did not work long enough under Social Security to qualify for Medicare.

Work under Social Security is figured in credits. Please read the enclosed pamphlet, “How You Earn Social Security Credits,” which explains how the credits are earned.For  (2)  to qualify for Medicare,  (3)  needed to have earned  (4)  credits.  (5)  earned  (6)  credits. These figures are based on  (7)   (8)  date of birth,  (9)  .

In addition,  (10)  cannot qualify for medical insurance because  (11)  neither a United States citizen nor an alien lawfully admitted for permanent residence and residing in the United States for at least 5 years in a row before filing for Medicare.

Fill-ins:

(1) “You”/NHFN

(2) “you”/SN

(3) “you”/NHSN

(4) Quarters of coverage required (QCR) in format 40

(5) “She”/“He”

(6) Quarters of coverage earned

(7) “your”/NHSN possessive

(8) “correct”/null

(9) birthdate in the format, June 10, 1990

(10) “you”/“she”/“he”

(11) “you are”/“she is”/“he is”

CTZ007 Medicare Disallowance - Citizen

 (1)  cannot qualify for Medicare because  (2)  neither a United States citizen nor an alien who was lawfully admitted for permanent residence and residing in the United States for at least five years in a row before filing for Medicare.

 (3)  may be able to buy Medicare coverage in the future.  (4)  can buy Medicare only after  (5)  lived in the United States for five years in a row. These must be the five years right before  (6)  for Medicare. Also as an alien,  (7)  must be lawfully admitted for permanent residence.

Fill-ins:

(1) “You”/“She”/“He”

(2) “you are”/“she is”/“he is”

(3) “You”/“She”/“He”

(4) “You”/“She”/“He”

(5) “you have”/“she has”/“he has”

(6) “you apply”/“she applies”/“he applies”

(7) “You”/“She”/“He”

DAAC01 Caption

About  (1)  Disability

Fill-in:

(1) “Your”/“Her”/“His”

DAAC02 Caption

 (1)  Must Go For Required Treatment

Fill-in:

(1) “You”/“She”/“He”

DAA001 DAA – Award Notice – Reason for Disability is Drug Addiction, Alcoholism or Both

Because  (1)  a contributing factor material to  (2)  disability, the law says that:

 (3)  must go for treatment for  (4)   (5)  when it is available, and make progress in  (6)  treatment or  (7)  payments will be stopped, and

 (8)  can get payments for a total of only 36 months in which treatment is available to  (9)  , and

If we must stop  (10)  payments for 12 months in a row because  (11)  not go for the required treatment or  (12)  not make progress in  (13)  treatment,  (14)  entitlement to benefits will end the next month. In order to receive benefits again,  (15)  will have to file a new application, and

an organization or person, called a representative payee, must receive  (16)  payments for  (17)  . It will be  (18)  payee's duty to manage  (19)  payments and see that  (20)  needs are met, and

If we owe  (21)  for past months, we cannot pay all of the back payments in one lump sum. Instead, we must pay this money over a period of months. The total amount we can pay each month cannot be more than two times  (22)  regular monthly payment amount. By total amount we mean  (23)  monthly payment and any back payment we are paying  (24)  .

Fill-ins:

(1) “drug addiction is”/“alcoholism is”/“drug addiction and alcoholism are”

(2) “your”/“her”/“his”

(3) “you”/“she”/“he”

(4) “your”/“her”/“his”

(5) “drug addiction”/“alcoholism”/“drug addiction and alcoholism”

(6) “your”/“her”/“his”

(7) “your”/“her”/“his”

(8) “you”/“she”/“he”

(9) “you”/“her”/“him”

(10) “your”/“her”/“his”

(11) “You do”/“She does”/“He does”

(12) “do”/“does”

(13) “your”/“her”/“his”

(14) “your”/“her”/“his”

(15) “you”/“she”/“he”

(16) “your”/“her”/“his”

(17) “you”/ “her”/ “him”

(18) “your”/“her”/“his”

(19) “your”/“her”/“his”

(20) “your”/“her”/“his”

(21) “you”/“her”/“him”

(22) “your”/“her”/“his”

(23) “your”/“her”/“his”

(24) “you”/“her”/“him”

DAAR01 Payments End 1/1/97

Because  (1)  a contributing factor material to  (2)  disability, the law says that:

 (3)  must go for treatment for  (4)   (5)  when it is available, and make progress in  (6)  treatment or  (7)  payments will be stopped, and

 (8)  payments will end January 1, 1997 even if  (9)  in treatment, and

An organization or person, called a representative payee, must receive  (10)  payments for  (11)  . It will be  (12)  payee's duty to manage  (13)  payments and see that  (14)  needs are met, and

If we owe  (15)  for past months, we cannot pay all of the back payments in one lump sum. Instead, we must pay this money over a period of months. The total amount we can pay each month cannot be more than two times  (16)  regular monthly payment amount. By total amount, we mean  (17)  monthly payment and any back payment we are paying  (18)  .

Fill-ins:

(1) “drug addiction is”/“alcoholism is”/“drug addiction and alcoholism are”

(2) “your”/“her”/“his”

(3) “you”/“she”/“he”

(4) “your”/“her”/“his”

(5) “drug addiction”/“alcoholism”/“drug addiction and alcoholism”

(6) “your”/“her”/“his”

(7) “your”/“her”/“his”

(8) “your”/“her”/“his”

(9) “you are”/“she is”/“he is”

(10) “your”/“her”/“his”

(11) “you”/“her”/“him”

(12) “your”/“her”/“his”

(13) “your”/“her”/“his”

(14) “your”/“her”/“his”

(15) “you”/“her”/“him”

(16) “your”/“her”/“his”

(17) “your”/“her”/“his”

(18) “you”/“her”/“him”

DAA002 DAA – Award Notice – Treatment Required by Law

We will refer  (1)  to an agency that will decide what treatment is right for  (2)  . That agency will contact  (3)  about  (4)  treatment and when it is available. It will also check whether  (5)  for treatment and report  (6)  progress to us.

The law says that if  (7)  not go for treatment when it is available or  (8)  not make progress in  (9)  treatment, we must stop  (10)  payments. If this happens, we will not begin paying  (11)  right away even when  (12)   (13)  treatments again and  (14)  making progress.

The first time we have to stop paying  (15)  ,  (16)  payments will not begin until  (17)  back in treatment for 2 months in a row.

The second time we have to stop paying  (18)  ,  (19)  payments will not begin until  (20)  back in treatment for 3 months in a row.

The third time we have to stop paying  (21)  ,  (22)  payments will not begin until  (23)  back in treatment for 6 months in a row.

Fill-ins:

(1) “you”/“her”/“him”

(2) “you”/“her”/“him”

(3) “you”/“her”/“him”

(4) “your”/“her”/“his”

(5) “you go”/“she goes”/“he goes”

(6) “your”/“her”/“his”

(7) “you do”/“she does”/“he does”

(8) “do”/“does”

(9) “your”/“her”/“his”

(10) “your”/“her”/“his”

(11) “you”/“her”/“him”

(12) “you start”/“she starts”/“he starts”

(13) “your”/“her”/“his”

(14) “are”/“is”

(15) “you”/“her”/“him”

(16) “your”/“her”/“his”

(17) “you are”/“she is”/“he is”

(18) “you”/“her”/“him”

(19) “your”/“her”/“his”

(20) “you are”/“she is”/“he is”

(21) “you”/“her”/“him”

(22) “your”/“her”/“his”

(23) “you are”/“she is”/“he is”

DAAR06 Payment to Prevent Homelessness Not Paid

We did not pay  (1)  any additional money for housing costs from  (2)  past-due payments. This is because  (3)  .

Fill-ins:

(1) “you”/“her”/“him”

(2) “your”/“her”/“his”

(3)

Choice 1: you did not give us evidence showing you needed the extra money *

Choice 2: you can pay your housing costs from your regular monthly payments *

(*) indicates that the fill-ins are manual

DDD004 New Claim or Reconsideration – Same Issue as Previously Denied Disability Claim

We denied  (1)  previous claim for disability benefits. Our previous decision covered the same issues as this claim. We do not have any new information to change our decision.

Fill-ins:

(1) “your”/FN

DDD005 New Claim or Reconsideration after Prior Substantive Denial Alleging Onset after Insured Status Last Met

The information you gave us does not show that there was any change in  (1)  health before  (2)  . This was when  (3)  last met the earnings requirement for receiving benefits.

Fill-ins:

(1) “your”/FN possessive

(2) date disability last met

(3) “you”/“she”/“he”

DDD006 Widow(er) Files Request for Reconsideration after Substantive Denial – Prior Medical Adjudicated after Prescribed Period Last Expired

The information you gave us does not show that there was any change in  (1)  health before  (2)  . This was the last date  (3)  could qualify for benefits as a disabled  (4)  .

Fill-ins:

(1) “your”/FN possessive

(2) date disability last met

(3) “you”/“she”/“he”

(4) “widow”/“widower”

DDD007 Disabled Child Files Request for Reconsideration after Substantive Denial – Prior Denial Adjudicated after Child Attained Age 22

The information you gave us does not show that there was any change in  (1)  health before  (2)  . This was the last date  (3)  could qualify for benefits as a disabled child.

Fill-ins:

(1) “your”/“her”/“his”

(2) month/day/year=age 22 years

(3) “you”/“she”/“he”

DDD008 Number Holder Not Insured at Alleged Onset or Later – New Claim or Reconsideration Affirms Denial

 (1)   (2)  not qualify for disability benefits because  (3)  not worked long enough under Social Security.

We figure work under Social Security in credits. Please read the enclosed pamphlet, “How You Earn Social Security Credits,” which explains how the credits are earned and how many a person must have to receive benefits.

Since  (4)  not have enough work credits to qualify for benefits, we did not make a decision about whether  (5)  disabled under our rules.

Fill-ins:

(1) “You”/FN

(2) “do”/“does”

(3) “you have”/“she has”/“he has”

(4) “You do”/“She does”/“He does”

(5) “you are”/“she is”/“he is”

DDD009 Widow(er) Prescribed Period Expired Before Alleged Onset – Initial or Reconsideration Decision

We cannot pay  (1)  because  (2)  not disabled within a 7-year period. To qualify,  (3)  would need to meet any one of the following rules:

 (4)  disability began within 7 years after the month that the worker died.

 (5)  disability began within 7 years after the month that  (6)  benefits as a  (7)  ended.

 (8)  disability began within 7 years after the month that  (9)  earlier period of disability ended.

For  (10)  to qualify for benefits,  (11)  disability must have begun before  (12)  , the date  (13)  7-year period ended. You told us  (14)  first became disabled on  (15)  . This date is after the 7-year period.

Since  (16)  not meet the 7-year period requirement, we did not make a decision about whether  (17)  disabled under our rules.

Fill-ins:

(1) “you”/FN

(2) “you were”/“she was”/“he was”

(3) “you”/“she”/“he”

(4) “your”/“her”/“his”

(5) “your”/“her”/“his”

(6) “your”/“her”/“his”

(7) “mother”/“father”

(8) “your”/“her”/“his”

(9) “your”/“her”/“his”

(10) “you”/“her”/“him”

(11) “your”/“her”/“his”

(12) prescribed period end date in format January 1991

(13) “your”/“her”/“his”

(14) “you”/“she”/“he”

(15) alleged onset date

(16) “You do”/“She does”/“He does”

(17) “you are”/“she is”/“he is”

DDDR10 New DWB Application – Prior Denial Under Same Law

 (1)   (2)  not qualify for benefits because this application concerns issues which were decided when an earlier claim was denied. We do not have any information which would cause us to change our earlier decision.

The information you gave us does not show that there was any change in  (3)  health before  (4)  . This was the last day  (5)  could qualify for benefits as a disabled  (6)  .

If you have any new information about  (7)  health on or before  (8)  , you need to give it to us so we can review it.

Fill-ins:

(1) “You”/FN

(2) “do”/“does”

(3) “your”/“her”/“his”

(4) prescribed period end date

(5) “you”/“she”/“he”

(6) “widow”/“widower”

(7) “your”/“her”/“his”

(8) prescribed period end date

DDDR11 Death Within 5 Months of Disability Onset

 (1)  did not qualify for disability benefits because to qualify  (2)  had to be disabled at least 5 full calendar months in a row before death. This requirement is not met because  (3)  was given as the date the disability started and  (4)  as the date of death.

Fill-ins:

(1) NH name

(2) “she”/“he”

(3) alleged onset date

(4) NH's date of death

DDD012 Reporting Health Changes after New Claim or Reconsideration Disallowance

If you have any new information about  (1)  health on or before  (2)  , please send it to us. We need to review it to see if we can change our previous decision.

Fill-ins:

(1) “your”/FN possessive

(2) HA - date last insured/DWB - date prescribed period last met/ DAC - date age 22 attained

DDD017 Number Holder Attained Full Retirement Age in Waiting Period or Earlier Based on Alleged Onset – No Earlier Onset Possible

To qualify for benefits, a person must be disabled for at least 5 full calendar months in a row before reaching full retirement age. You told us that  (1)  became disabled on  (2)  . Our records show that  (3)  reached full retirement age,  (4)   (5)   (6)   (7)  in  (8)  .

Fill-ins:

(1) you/Ms. plus beneficiary's last name/Mr. plus beneficiary's last name

(2) Onset date (month/day/year)

(3) “you”/“she”/“he”

(4) full retirement age, in format “65”

(5) “and”/NULL

(6) additional FRA months in format “2”/NULL

(7) months/NULL

(8) NH's DOB plus full retirement age, in the format June 1998

DDD018 Number Holder Attained Age 65 in Waiting Period or Earlier – Onset Established

To qualify for benefits, a person must be disabled for at least 5 full calendar months in a row before reaching full retirement age. Using the facts you gave us, we found that  (1)  did not become disabled under our rules until  (2)  . Our records show that  (3)  reached full retirement age,  (4)   (5)   (6)   (7)  in  (8)  .

Fill-ins:

(1) you/Ms. plus beneficiary's last name/Mr. plus beneficiary's last name

(2) Current DDO (month/day/year)

(3) “you”/“she”/“he”

(4) full retirement age, in format “65”

(5) and/null

(6) show additional FRA months in format “2”/null

(7) months/null

(8) NH-DOB plus full retirement age, in the format June 1998

DEPR07 Disallowance – Child not Dependent

 (1)  not qualify for benefits as a child on  (2)  Social Security record  (3)  . To qualify,  (4)  must have been living with or receiving contributions from  (5)  when:

  •  (6)  applied for benefits, or

  •  (7)  became disabled, or

  •  (8)  became entitled to benefits, or

  •  (9)  died.

The facts we have do not show that any of these requirements is met.

Fill-ins:

(1) “PN does”/“You do”

(2) NH name possessive

(3)

“because she was adopted by someone else”/“because he was adopted by someone else”/ “because you were adopted by someone else”/null

(4) “you”/“she”/he”

(5) SN of NH

(6) “you”/“she”/“he”

(7) SN of NH

(8) SN of NH

(9) “she”/“he”

DEPR08 Disallowance – Adopted Child

 (1)  not qualify for benefits as an adopted child on  (2)  Social Security record because  (3)  did not live with or receive at least half  (4)  support from  (5)  for the last year before  (6)  adoption became final.

Fill-ins:

(1) “You do”/“She does”/“He does”

(2) NH's name

(3) “you”/“she”/“he”

(4) “your”/“her”/“his”

(5) SN of NH

(6) “your”/“her”/“his”

DEPR09 Dependency Requirement - Disallowance

To qualify for child's benefits as a dependent grandchild or step grandchild on  (1)  Social Security record,  (2)  must have:

begun living with  (3)  before age 18; and

lived with  (4)  in the United States and received one-half support from  (5)  throughout the year before  (6)   (7)  .

The facts we have do not show that these requirements are met.

Fill-ins:

(1) NH's name

(2) “you”/FN

(3) “her/him”

(4) “her/him”

(5) “her/him”

(6) “she/he”

(7) “became entitled to disability benefits”/”became entitled to retirement benefits/died/became disabled” *

(*) indicates that fill-in is manual

DEP010 Claims Where a Child is Adopted by the Number Holder's Surviving Spouse but the Dependency Requirement is not Met

 (1)  not qualify for child's benefits on  (2)  Social Security record because  (3)  not living with  (4)  or receiving at least one-half support from  (5)  when  (6)  died.

Fill-ins:

(1) “She does”/“He does”/“You do”

(2) NH-NAME possessive

(3) “she was”/“he was”/“you were”

(4) Ms. Plus NH's SURNAME/Mr. Plus NH's SURNAME

(5) Ms. Plus NH's SURNAME/Mr. Plus NH's SURNAME

(6) “she”/“he”

DEP011 Disallowance – Child Not Living With

 (1)  not qualify for child's benefits on  (2)  Social Security record because  (3)  not living in  (4)  household when  (5)  died.

Fill-ins:

(1) “You do”/“She does”/“He does”

(2) NH's name possessive

(3)

“[3a] natural mother was” or “PN was”

[3a] “your”/“her”/“his”

(4) SN of NH

(5) “she”/“he”

DEPR12 Disallowance – Grandchild Adopted by Surviving Spouse

 (1)  not qualify for child's benefits on  (2)  Social Security record because:

 (3)  parent or stepparent was living in the same household as  (4)  , and

 (5)  receiving support from  (6)  parent or stepparent when  (7)  died.

Fill-ins:

(1) “You do”/“She does”/ “He does”

(2) NH's name

(3) “your”/“her”/“his”

(4) SN of NH

(5) “You were”/“she was”/“he was”

(6) “your”/“her”/“his”

(7) NHSN

DEPR13 Disallowance - Grandchild

To qualify for benefits as a grandchild or step grandchild on  (1)  Social Security record,  (2)  natural or adoptive parents must have been deceased or disabled when:

 (3)  became disabled, or

 (4)  became entitled to benefits, or

 (5)  died.

The facts we have do not show that any of these requirements is met.

Fill-ins:

(1) NH's name

(2) “your”/“her”/“his”

(3) NH's surname

(4) “she”/“he”

(5) “she”/“he”

DEP015 Parent Disallowance – Proof Not Within Time Limit

 (1)  not qualify for parent's benefits because we did not receive proof within the time limit that  (2)  received half of  (3)  support from  (4)  . We needed this proof within 2 years of either the:month  (5)  applied for disability, or date  (6)  died.The facts we have do not show that either requirement is met.

Fill-ins:

(1) “You do”/“She does”/ “He does”

(2) “you”/“she”/“he”

(3) “your”/“her”/“his”

(4) NH's name

(5) “she”/“he”

(6) “she”/“he”

DEP016 Parent Disallowance - Support

 (1)  not qualify for parent's benefits because  (2)  not receiving at least half  (3)  support from  (4)  when  (5)  became disabled or died.

The facts we have do not show that any of these requirements is met.

Fill-ins:

(1) “You do”/“She does”/ “He does”

(2) “you were”/“she was”/“he was”

(3) “your”/“her”/“his”

(4) NH's name

(5) “she/he”

DEP020 Auxiliary Stepchild Disallowance – Dependency Requirements Not Met

To qualify for benefits on a stepparent's record, a child must have been receiving at least one half of his or her support from the stepparent. The child must have been receiving this support  (1)  or, if the stepparent was disabled until entitlement to retirement or disability benefits, when that parent:

last became disabled; or

last became entitled to disability benefits; or

became entitled to retirement insurance benefits.

Fill-in:

(1) when the stepparent died/when he or she applied for benefits

DIBC01 Caption

The Date You Became Disabled

DIBC02 Caption

The Basis For Our Decision

DIBC03 Caption

Our Decision

DIB001 5 Month Waiting Period – Month of Entitlement

To qualify for disability benefits,  (1)  must be disabled for five full calendar months in a row. The first month  (2)  entitled to benefits is  (3)  .

Fill-ins:

(1) “you”/“FN”

(2) “you are”/“he is”/“she is”

(3) date of entitlement to disability

DIB002 Lead-in Language for Closed Period and Later Onset Date Allowance

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-ins:

(1) “you”/FN

(2) “you”/“she”/“he”

(3) “meet”/“meets”

(4) “you”/“she”/“he”

(5) “qualify”/“qualifies”

(6) “period of disability”/“monthly disability benefits from Social Security”

(7) date of entitlement to disability

DIB003 DIB/DWB/CDB Closed Period

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-ins:

(1) FN possessive/”her”/”his”/”your”

(2) effective date (Date beneficiary went into T8/T6 LAF status in the format “Month YYYY”)

(3) ”her”/“him”/“you”

(4) date of entitlement in the format “Month YYYY)

(5) ”her”/“him”/“you”

(6) “her”/“his”/“your”

(7) “she was”/“he was”/“you were”

(8) effective date (Date beneficiary went into T8/T6 LAF status - 3 months in the format “Month YYYY”)

DIB004 State Agency and Medical Doctor Participation in 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:

(1) “your”/FN possessive

DIB005 Medical Doctor Participation in Non-State Decision

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

Fill-in:

(1) “your”/FN possessive

DIB006 Benefits Payable up to 12 Months before DIB Filing Date

By law, we can pay benefits no earlier than 12 months before the month of filing. Since  (1)  filed for benefits on  (2)  , monthly payments will begin  (3)  .

Fill-ins:

(1) “you”/FN in format “Mr. Jack Jones”

(2) DOF in format “January 10, 1993”

(3) DOEC in format “April 1994”

DIB014 Benefits Terminated – DIB Cessation

The last month for which  (1)   (2)  entitled to benefits was  (3)  .

Fill-ins:

(1) Number holder's name, possessive/your

(2) family was/wife was/husband was/child was/children were

(3) effective date minus one month in format April 1997

DIB015

The trained staff who decided this case work for the state but used our rules.

DID029 Request for Change in Mailing Address/Direct Deposit Information for ALJ Level Award Notices upon Effectuation

Please tell us if  (1)  mailing address or direct deposit information changes. We need this information to deposit  (2)  payments on time and send you important letters about  (3)  payments.

Fill-in:

(1) “your”/FN possessive

(2) “your”/“his”/“her”

(3) “your”/“his”/“her”

DOBC01 Caption

 (1)  Date of Birth

Fill-in:

(1) SN

DSL036 Lead-in for all Reconsideration Disallowances

You asked us to take another look at  (1)  claim for benefits. Someone who did not make the first decision reviewed  (2)  case, including any new facts we received, and found that our first decision was correct.

Fill-ins:

(1) “your”/FN possessive

(2) “your”/“her”/“his”

DSL037 Disallowance of Auxiliary/Survivor Benefits Due to Entitlement to Higher Benefits on Primary Account

 (1)   (2)  not qualify for  (3)  benefits because  (4)   (5)  entitled to an equal or larger benefit on another Social Security record.

Fill-ins:

(1) “you”/“she”/“he”

(2) “do”/“does”

(3) type of benefit

(4) “you”/“she”/“he”

(5) “are”/“is”

DSL038 Disallowance Introduction

We are writing to tell you that  (1)  not qualify for  (2)   (3)  .

Fill-ins:

(1) “you do”/FN “does”

(2) “U.S.”/null

(3) type of benefit (e.g. Medicare, retirement benefits, disability benefits, etc.)

DSL039 Auxiliary Disallowance – Number Holder not Entitled

 (1)  not qualify for Social Security benefits on  (2)  record because  (3)  is not entitled to any benefits.

Fill-ins:

(1) “You do”/“She does”/“He does”

(2) NH's name possessive

(3) “she”/“he”

DSL041 Parent Disallowance – Number Holder Alive

 (1)  not qualify for parent's benefits on  (2)  Social Security record because  (3)  is alive. We can only pay parent's benefits in the event of  (4)  death.

Fill-ins:

(1) “You do”/“She does”/“He does”

(2) NH's name possessive

(3) “she”/“he”

(4) “her”/“his”

DSL045 English Translation for Spanish Cover Letter – Affirmation of Denial on Reconsideration – Domestic/Foreign/Mexico Address

Your claim for Social Security benefits was reviewed as you requested. We regret that we were unable to approve it. A person who did not make the first decision carefully reviewed all of the evidence and information before making this decision.

DSL050 English Translation for Spanish Cover Letter – Denials/Disallowances – Domestic/Foreign Address

We are unable to approve your claim for Social Security benefits. The enclosed explanation in English tells you why. If you need help translating it, ask someone familiar with both English and Spanish to help you. Or contact any Social Security office.

DSL055 English Translation for Spanish Cover Letter – Denials/Disallowances – Mexico Address

We are unable to approve your claim for Social Security benefits. The enclosed explanation in English tells you why. If you need help translating it, ask someone who understands both English and Spanish to help you, or contact any Social Security office or the nearest U.S. Embassy or Consulate.

ENC003 Enclosure Remark for Copy of Cover Notice/Version 1

Enclosure(s):

 (1) 

Fill-in:

(1) Name or names of enclosures

ENC003 Enclosure Remark for Copy of Cover Notice/Version 2

Enclosure(s):

(1)

Letter to (2)

Fill-ins:

Fill-in (1) Name or names of enclosures

Fill-in (2) Addressee

ENTR01 Entitlement Conversions – Award for a Young Wife/Husband, Changes to an Aged Wife/Husband and again Changes to a Divorced Spouse (2 Conversions)

 (1)  entitled to spouse benefits based on having a child in  (2)  care for  (3)  .  (4)  entitled to spouse benefits based on  (5)  age for  (6)  . Beginning  (7)  ,  (8)  entitled to divorced spouse benefits.

Fill-ins:

(1) BGN plus BLN plus “was”/You were

(2) “her”/“his”/“your”

(3) Month YYYY/Month YYYY and Month YYYY/Month YYYY through Month YYYY

(4) Ms. plus BLN plus “was”/Mr. plus BLN plus “was”/You were

(5) “her”/“his”/“your”

(6) Manual fill-in 1 - entitlement period for young wife/husband in the format “Month YYYY” or “Month YYYY and Month YYYY”, or “Month YYYY through Month YYYY”

(7) entitlement start date for aged wife/husband in format - Month YYYY

(8) “she is”/“he is”/“you are”

ENTR02 Entitlement Conversions – Award for Aged Wife/Husband, Changes to Divorced Wife/Husband and Changes (Again) Back to an Aged Wife/Husband (2 Conversions)

 (1)  entitled to spouse benefits for  (2)  .  (3)  entitled to divorced spouse benefits for  (4)  . Beginning  (5)  ,  (6)  entitled to spouse benefits again.

Fill-ins:

(1) BGN plus BLN plus “was”/you were

(2) Month YYYY/Month YYYY and Month YYYY/Month YYYY through Month YYYY

(3) Ms. plus BLN plus “was”/Mr. plus BLN plus “was”/you were

(4) Use the value of manual Fill-in 1 - entitlement dates for divorced spouse benefits in the format “Month YYYY” or “Month YYYY and Month YYYY”, or “Month YYYY through Month YYYY”

(5) Month YYYY

(6) “she is”/“he is”/“you are”

ENT009 Lump Sum Award - Introductory

 (1)   (2)  entitled to a Social Security payment of  (3)  because of the death of  (4)  .  (5) 

Fill-ins:

(1) “You”/FN

(2) “is”/“are”

(3) money amount ($xxx.xx)

(4) NH's name

(5) You will receive the payment around [5a].

[5a] date (mm/dd/yy)

ENTR11 Scope of Application Restricted

You told us that you were not applying for  (1)  benefits. For this reason, we did not consider whether  (2)  might be entitled to these benefits.

Fill-ins:

(1) type of benefit *

(2) “you”/SN

(*) indicates that fill-in is manual

ENT015 DIB Denial Over RIB Entitlement

Although  (1)  cannot receive disability benefits,  (2)  still entitled to retirement benefits.

Fill-ins:

(1) “you”/Ms. plus beneficiary's last name/Mr. plus beneficiary's last name

(2) “you are”/“she is”/“he is”

ENTR18 Child Disability Claim Pending

We are still working on your child's claim for disability benefits. If your child becomes entitled to these benefits, you might receive a larger benefit. When we decide whether or not  (1)  is entitled, we will let you know.

Fill-in:

(1) FN

(*) indicates that fill-in is manual

ENT019 Deferred Award

 (1)   (2)  entitled to monthly  (3)  benefits beginning  (4)  . However, we cannot pay  (5)  until  (6)  .

Fill-ins:

(1) “You”/FN

(2) “is”/“are”

(3) type of benefit

(4) month and year of entitlement

(5) “you”/“her”/“him”

(6) month and year of payment

ENT020 Entitlement to Monthly Benefit - Introductory

 (1)   (2)  entitled to a monthly  (3)  benefit for  (4)   (5)   (6)  .

Fill-ins:

(1) FN

(2) “are”/“is”

(3) type of benefit (e.g., retirement)

(4) DOEC in format “January 1988”

(5) “through”/null

(6) DOST minus one month in format “January 1988”/null

ENT021 Benefits Suspended Due to GPO

However, we cannot pay  (1)  beginning  (2)  because two-thirds the amount of  (3)  government pension is equal to or larger than  (4)  monthly Social Security benefit.

Fill-ins:

(1) SN in format “Mr. Jones” or “you”

(2) Date in format “May 1993”

(3) “your”/“her”/“his”

(4) “your”/“her”/“his”

ENT023 Suspension Months Involved

However, we cannot pay  (1)   (2)   (3)   (4)   (5)  .

Fill-ins:

(1) “you”/SN

(2) “at this time”/“for”/“beginning”

(3) first month and year for which being suspended/null

(4) “and”/“through”/null

(5) last month and year for which being suspended/null

ENT024 Multiple Suspension Reasons Involved

Although  (1)   (2)  entitled, we cannot pay  (3)  for some months.

Fill-ins:

(1) “you”/FN

(2) “are”/“is”

(3) “your/her/him”

ENTR25 Reduced Benefits

 (1)  chose to receive reduced  (2)  benefits that month.

Fill-ins:

(1) “You”/SN

(2) “husband's”/“wife's”

ENT026 Award Introduction

 (1)   (2)  entitled to monthly  (3)  benefits beginning  (4)  .

Fill-ins:

(1) “You”/FN

(2) “are”/“is”

(3) type of benefit

(4) month and year of entitlement or election

ENTR26 Delayed Claimant

We will notify  (1)  later concerning  (2)  claim(s).

Fill-ins:

(1) “you”/beneficiary's name

(2) name(s) of delayed claimant(s) possessive *

(*) indicates that fill-in is manual

ENT027 Simultaneous Awards – One Notice Sent

 (1)  entitled to monthly  (2)  benefits beginning  (3)  .  (4)  also entitled to  (5)  benefits on claim number  (6)  beginning  (7)  .

Fill-ins:

(1) “You are”/“She is”/“He is”

(2) disability/retirement

(3) Date fill-in

(4) “You are”/“She is”/“He is”

(5) type of benefit

(6) SSN of survivor/auxiliary claim

(7) Date fill-in

ENT028 Simultaneous Award – Separate Payments (Used on Primary Award Notice)

 (1)  also entitled to  (2)  benefits on claim number  (3)  beginning  (4)  . We are sending  (5)  another letter about these benefits.

Fill-ins:

(1) “You are”/“She is”/“He is”

(2) type of benefit

(3) SSN of survivor/auxiliary claim

(4) Date fill-in

(5) “you”/“her”/“him”

ENT029 Simultaneous Awards – Separate Payments (Used on Auxiliary/Survivor Award Notice)

 (1)  also entitled to benefits on  (2)  own earnings record beginning  (3)  . We are sending  (4)  another letter about these benefits.

Fill-ins:

(1) “you are”/“she is”/“he is”

(2) “your”/“her”/“his”

(3) Date fill-in

(4) “you”/“her”/“him”

ENT030 Suspension Months Involved (2 Periods)

However, we cannot pay  (1)  for  (2)   (3)   (4)  and  (5)   (6)   (7)   (8)  .

Fill-ins:

(1) “You”/SN

(2) month and year

(3) “and”/“through”/null

(4) month and year/null

(5) “beginning”/null

(6) month and year

(7) “and”/“through”/null

(8) month and year/null

ENT031 Suspension Months Involved (3 Periods)

However, we cannot pay  (1)  for  (2)   (3)   (4)  ,  (5)   (6)   (7)  and  (8)   (9)   (10)   (11)  .

Fill-ins:

(1) “you”/SN

(2) month and year

(3) “and”/“through”/null

(4) month and year/null

(5) month and year

(6) “and”/“through”/null

(7) month and year/null

(8) “beginning”/null

(9) month and year

(10) “and”/“through”/null

(11) month and year/null

ENT032 Suspension Months Involved (4 Periods)

However, we cannot pay  (1)  for  (2)   (3)   (4)  ,  (5)   (6)   (7)   (8)   (9)   (10)  and  (11)   (12)   (13)   (14)  .

Fill-ins:

(1) “you”/SN

(2) month and year

(3) “and”/“through”/null

(4) month and year/null

(5) month and year

(6) “and”/“through”/null

(7) month and year/null

(8) month and year

(9) “and”/“through”/null

(10) month and year/null

(11) “beginning”/null

(12) month and year

(13) “and”/“through”/null

(14) month and year/null

ENT034 Suspense Due to Technical Entitlement

However, we cannot pay  (1)  beginning  (2)  because  (3)  entitled to an equal or larger benefit on another record.

Fill-ins:

(1) “you”/“her”/“him”

(2) effective date in format April 1997

(3) “you are”/“she is”/“he is”

ENT035 Future Payments

Any future payments will be based on  (1)  current monthly benefit rate of  (2)  .

Fill-ins:

(1) “your”/SN possessive

(2) MBA

ENT037 Entitlement Introductory Statement

We have approved  (1)  application for  (2)  benefits.  (3)  entitlement date is  (4)  .

Fill-ins:

(1) “your”/FN possessive

(2) type of benefit

(3) “your”/“her”/“his”

(4) date of entitlement

ENT038 No Benefits Payable – Maximum Already Being Paid

We have approved  (1)  application for  (2)  benefits.  (3)  entitlement date is  (4)  . However, we cannot pay  (5)  any benefits because all of the money we can pay on this record is already being paid to  (6)  .

Fill-ins:

(1) FN possessive in format “Mr. Jack Jones” or “your”

(2) “spouse's/child's/parent's”

(3) “your”/“her”/“his”

(4) DOEC in format “July 1992”

(5) “you”/“her”/“him”

(6) Number holder's FN

ENT040 LSDP and Survivor Benefit Awarded

 (1)   (2)  entitled to monthly  (3)  benefits beginning  (4)  .  (5)   (6)  also entitled to a Social Security payment of  (7)  because of the death of  (8)  .

Fill-ins:

(1) FN in format “Mr. Jack Jones” or “You”

(2) “are”/“is”

(3) “widow's”/“widower's”/ “child's”/“disabled widow's”/“disabled widower's”/“mother's”/ “father's”

(4) DOEC in format “May 1993”

(5) “you”/“she”/“he”

(6) “are”/“is”

(7) LSAP in format “$999.99”

(8) Number holder's name

ENT041 Entitlement Conversion from a Young Wife/Husband to an Aged Wife/Husband

 (1)  entitled to spouse benefits based on having a child in  (2)  care for  (3)  . Beginning  (4)   (5)  became entitled to spouse benefits based on  (6)  age.

Fill-ins:

(1) BGN plus BLN plus “is”/You are

(2) “her”/“his”/“your”

(3) Month YYYY/Month YYYY and Month YYYY/Month YYYY through Month YYYY

(4) Month YYYY

(5) “she”/“he”/“you”

(6) “her”/“his”/“your”

ENT043 Entitlement Conversion for Either a Mother/Father to a “widow”/”widower” or an Aged Wife/Husband to a Divorced Wife/Husband

 (1)  entitled to  (2)  benefits for  (3)  . Beginning  (4)  ,  (5)  entitled to  (6)  benefits.

Fill-ins:

(1) BGN plus BLN plus “was”/ “You were”

(2) “mother's”/“father's”/“spouse's”

(3) Month YYYY and Month YYYY/Month YYYY through Month YYYY

(4) Month YYYY

(5) Ms. plus BLN plus “is”/Mr. plus BLN plus “is”/“you are”

(6) “widow's”/“widower's”/“divorced wife”/“divorced husband”

ENT048 Period of Suspense (Due to Payee Development) Followed by Payment of Current Benefits Only

We are withholding payment for  (1)  until we decide the best way to make payments.

Fill-ins:

(1) Month YYYY

(2) Month YYYY and Month YYYY

(3) Month YYYY through Month YYYY

ENT050 English Translation for Spanish Cover Letter – Award – Domestic/Foreign Address

Your claim for Social Security benefits has been approved. The enclosed information in English tells you why. If you need help translating it, please ask someone who understands both English and Spanish to help you. Or contact any Social Security office.

ENT055 English Translation for Spanish Cover Letter – Award – Mexico Address

Your claim for Social Security benefits has been approved. The enclosed explanation in English tells you why. If you need help translating it, ask someone who understands both English and Spanish to help you, or contact any Social Security office or the nearest U.S. Embassy or Consulate.

ENT056 Entitled on Another Record

We approved  (1)  claim for  (2)  benefits. However, we cannot pay  (3)  on  (4)  record because  (5)  entitled to an equal or larger benefit on another Social Security record.

Fill-ins:

(1) “your”/“her”/“his”

(2) type of benefit

(3) “you”/“her”/“him”

(4) NH-NAME (possessive)

(5) “you are”/“she is”/“he is”

ERN001 Reporting Your Earnings

Because your earnings may affect your Social Security benefits, we need to know how much you earn during the year. Usually, we get that information from:

the earnings your employer reports on your W-2; and

your self-employment earnings reported on your income tax return.

In previous years, Social Security beneficiaries were required to file a separate report with us. Now, you need to report your earnings to us after the end of the year only if:

You are eligible for the monthly earnings test and you earned less than the monthly exempt amount (in that case, you need to tell us so we can pay benefits for that month);

Some or all of the earnings shown on your W-2 were not earned in the year reported;

You earned wages above the exempt amount and you also had a net loss in self-employment;

Your W-2 shows employer-reported wages that you will include on a self-employment tax return (e.g., ministers);

You filed a self-employment tax return but you did not perform any services in your business;

You are a farmer and you get federal agricultural program payments or you have income from carry-over crops;

We withheld some benefits but you had no earnings for the year, (e.g., no wages reported, no self-employment income).

About mid-year, we probably will send you a message asking you to estimate your current and next year's earnings. Your estimates will help us avoid paying you too much or too little in benefits.

SSA Pub 16-012

ERNC01 Caption

Information About  (1)  Earnings Record

Fill-in:

(1) “Your”/SN possessive

ERNC13 Caption

Change(s) to  (1)  Earnings Record

Fill-in:

(1) “Your”/SN possessive

ERNC14 Caption

Reason For The  (1) 

Fill-in:

(1) “Change”/ “Changes”

ERND01 Dictated Text

ERNR09 LAG Earnings Alleged but not Posted

We used  (1)  earnings through  (2)  to figure the benefit amount. Later, we will refigure the benefit to include any earnings  (3)  had after  (4)  .  (5)  will not have to ask us to do this. After we have refigured the benefit amount, we will let you know about any increase.

Fill-ins:

(1) “your”/SN possessive

(2) last year included in the computation *

(3) “you”/“she”/“he”

(4) last year included in the computation *

(5) “you”/“she”/“he”

(*) indicates that the fill-in is manual

ERNR10 Earnings are not Wages

We could not use the money received from  (1)  for  (2)  because  (3)  .

Fill-ins:

(1) employer's name *

(2) year(s) *

(3) “the facts we have do not show that there was an employer-employee relationship”/“the money does not meet our requirements to be considered wages”/“the money was paid as a pension”/“the money was paid because of sickness or accident, and paid more than 6 months after work ended” *

(*) indicates that the fill-in is manual

ERNR11 Wage Determination Pending

We have not used the payments  (1)  received from  (2)  for  (3)  through  (4)  because we have not yet decided whether these payments are wages. We will let you know as soon as we make a decision.

Fill-in:

(1) “you”/SN

(2) employer's name *

(3) year *

(4) year *

(*) indicates that fill-in is manual

ERNR13 Change in Earnings - Chart

We have changed  (1)  earnings record as follows:

 (2) 

Amount Previously Posted

Corrected Amount

  

 (3) 

$  (4) 

$  (5) 

  

 (6) 

 (7) 

 (8) 

  

 (9) 

 (10) 

 (11) 

  

Fill-ins:

(1) SN

(2) “Year”/“Years” *

(3) the year affected *

(4) dollar amount of prior posting *

(5) correct earnings *

(6) second year affected *

(7) dollar amount of prior posting *

(8) correct earnings *

(9) third year affected *

(10) dollar amount of prior posting *

(11) correct earnings *

(*) indicates that fill-in is manual

ERNR14 Reason for Change in Earnings Record

We have changed  (1)  earnings record because  (2)  .

Fill-ins:

(1) “your”/SN possessive

(2) case specific *

(*) indicates that fill-in is manual

ERNR15 Pre-LAG Earnings Added – No Previous Posting

We have corrected  (1)  earnings record to show wages from  (2)  of $  (3)  for  (4)  .

Fill-ins:

(1) “your”/SN possessive

(2) employer's name *

(3) amount *

(4) year *

(*) indicates that fill-in is manual

ERNR16 Pre-LAG Earnings Adjustment – One Year

We have changed  (1)  earnings record for  (2)  from $  (3)  to $  (4)  because  (5)  .

Fill-ins:

(1) “your”/SN possessive

(2) year *

(3) amount previously posted *

(4) corrected amount *

(5) reason for the correction *

(*) indicates that fill-in is manual

ERNR17 Insured Status Not Met because Income as a Minister or Member of a Religious Order is Not Covered

We could not use income from  (1)  duties as a minister or member of a religious order for  (2)  .  (3) 

Fill-ins:

(1) “your”/SN possessive

(2) years involved in the format “YYYY” or “YYYY and YYYY” or “YYYY, YYYY, and YYYY” *

(3)

A. You did not file Form 2031 with IRS asking that these earnings be covered under Social Security. *

B. You filed Form 4361 with IRS asking that these earnings not be covered under Social Security.

(*) indicates that the fill-in is manual

ERNR18 Insured Status Not Met because Earnings in a Family Employment are not Covered Under Social Security

We could not use income for  (1)  because earnings from family employment were not covered under Social Security during this period.

Fill-in:

(1) years involved in the format “YYYY” or “YYYY and YYYY” or “YYYY, YYYY, and YYYY”

(*) indicates that the fill-in is manual

ERNR19 Insured Status Not Met because Number Holder Not U.S. Citizen When Employed on a Foreign Vessel or Aircraft

We could not use income for  (1)  . Work by a U.S. citizen is not counted when on a foreign vessel or aircraft outside the U.S. and the employer is not an American employer.

Fill-in:

(1) years involved in the format “YYYY” or “YYYY and YYYY” or “YYYY, YYYY, and YYYY”

(*) indicates that the fill-in is manual

ERNR20 Insured Status Not Met because Earnings from Domestic Work do Not Meet Threshold Amounts

We could not use income from  (1)  because it was not covered under Social Security. For  (2)   (3)  had to earn more than  (4)   (5)  from the employer.

Fill-ins:

(1) name of employer *

(2) years involved, in the format “YYYY” or “YYYY and YYYY” or “YYYY, YYYY and YYYY” *

(3) “you”/SN

(4)

A. “$50 in a 3-month period” *

B. money amount in the format $99999.99 *

(*) indicates that the fill-in is manual

ERNR21 Insured Status Not Met because Earnings from Agricultural Labor do Not Meet Threshold Amounts

We could not use income from  (1)  for  (2)  because  (3)  did not earn enough to be covered under Social Security. For  (4)   (5)  had to earn at least  (6)  .

Fill-ins:

(1) name of employer *

(2) years involved, in the format “YYYY” or “YYYY and YYYY” or “YYYY, YYYY and YYYY” *

(3) “you”/SN

(4)

A. “1951 through 1954” *

B. “1955 through 1956” *

C. “1957 through 1987” *

D. “1988 to the present” *

(5) “you”/SN

(6)

A. “a total of $50 or more” (used with 4-A) *

B. “$100 or more a year” (used with 4-B) *

C. “$150 or more a year” (used with 4-C) *

D. “$2500 or more a year” (used with 4-D) *

(*) indicates that the fill-in is manual

FOB003 Future Benefits – Own Retirement Benefit

You should get in touch with us about 3 months before  (1)   (2)  full retirement age,  (3)   (4)   (5)   (6)  . At that time, you will find out whether  (7)  will be entitled to higher benefits on  (8)  own record.

Fill-ins:

(1) “you”/SN

(2) “reach”/“reaches”

(3) full retirement age, in format “65”

(4) “and”/null

(5) show additional FRA months, in format “2”/null

(6) months/null

(7) “you”/“she”/“he”

(8) “your”/“her”/“his”

FOB005 Future Benefits – “widow”/”widower”

 (1)  may be able to receive  (2)  benefits at age 60, or at age 50 if  (3)  disabled. You should get in touch with us at that time to apply for the benefits.

Fill-ins:

(1) “You”/SN

(2) “widow's”/“widower's”

(3) “you are”/“she is”/“he is”

FOB020 Fully Insured for Retirement Benefits at Age 62

Based on  (1)  earnings and on  (2)  date of birth  (3)  ,  (4)  worked long enough under Social Security to qualify for retirement benefits at age 62.

Fill-ins:

(1) “your”/FN possessive

(2) “the”/ “your”/“her”/“his”

(3) “you gave us”/null

(4) “you have”/“she has”/“he has”

FOBR21 Separate Notices on Dual DIB Claims

If you have not already received a letter with our decision about  (1)  other disability application, you will receive one soon.

Fill-in:

(1) Full Name/your

FOBR22 DIB Payable Before DIB

The disability benefits to which  (1)   (2)  entitled are higher and payable before any retirement benefits to which  (3)  could be entitled. Since no retirement benefits are payable on  (4)  own record while  (5)  receiving disability benefits on the same record, we are taking no action on  (6)  retirement benefit application.

Fill-ins:

(1) “you”/FN

(2) “are”/“is”

(3) “you”/“she”/“he”

(4) “your”/“her”/“his”

(5) “you are”/“she is”/“he is”

(6) “your”/“her”/“his”

FRZ001 Disability Freeze

 (1)   (2)  for a period of disability beginning  (3)  . Although  (4)  will not receive checks during  (5)  period of disability, we will use the period to protect the amount of any benefit we might pay  (6)  family in the future. Future benefits on  (7)  record will be based on  (8)  average earnings. The period of disability ensures that if  (9)  relatively low earnings while disabled, the low earnings will not affect the average.

Fill-ins:

(1) “You”/FN

(2) “qualify”/“qualifies”

(3) onset date

(4) “you”/“she”/“he”

(5) “your”/“her”/“his”

(6) “your”/“her”/“his”

(7) “your”/“her”/“his”

(8) “your”/“her”/“his”

(9) “you have”/“she has”/“he has”

FRZ002 Disability Freeze – Potential Parent's Benefits

If either or both of  (1)  parents were receiving at least half of their support from  (2)  when  (3)  period of disability began, they may be eligible for benefits in the future. You would need to give us proof of this support within two years of the date the period of disability started.

Fill-ins:

(1) “your”/FN possessive

(2) “you”/“her”/“him”

(3) “your”/“her”/“his”

FRZ003 Statutory Blind Number Holder Allowed a Period of Disability (Freeze) but Denied Disability Benefits

We have reviewed  (1)  Social Security claim and find that  (2)  entitled to a period of disability but  (3)  not entitled to Disability Insurance Benefits. We have established a period of disability for  (4)  beginning  (5)  .

To be eligible for disability benefits a person must be unable to engage in substantial gainful activity. It has been determined from the evidence in  (6)  case that the work  (7)  done while disabled shows  (8)  ability to do some type of substantial gainful work. Thus,  (9)  not entitled to these benefits. Under special provisions of the Social Security law concerning blind persons, however,  (10)  entitled to a period of disability regardless of  (11)  ability to work.

The period of disability now established for  (12)  is important. It protects  (13)  right to insurance benefits and the benefit rights of  (14)  dependents and survivors.

Fill-ins:

(1) “your”/FN

(2) “you are”/“she is”/“he is”

(3) “you are”/“she is”/“he is”

(4) “you”/“her”/“him”

(5) onset date (date freeze begins)

(6) “your”/“her”/“his”

(7) “you have”/“she has”/“he has”

(8) “your”/“her”/ “his”

(9) “you are”/“she is”/“he is”

(10) “you are”/“she is”/“he is”

(11) “your”/“her”/“his”

(12) “you”/”her”/“him”

(13) “your”/“her”/“his”

(14) “your”/“her”/“his”

FRZ005 Statutory Blind Number Holder Allowed Freeze – Reporting Responsibilities

The period of disability established for  (1)  will end when  (2)  no longer  (3)  the definition of blindness or when  (4)  full retirement age,  (5)   (6)   (7)   (8)  , whichever occurs first. If before full retirement age,  (9)  unable to continue working because of  (10)  condition, or if  (11)  condition causes  (12)  to substantially reduce  (13)  work activity, you should get in touch with any Social Security office about filing an application for disability insurance benefits.

Fill-ins:

(1) “you”/SN

(2) “you”/“she”/“he”

(3) “meet”/“meets”

(4) “you reach/she reaches/he reaches”

(5) full retirement age, in format “65”

(6) “and”/null

(7) show additional FRA months, in format “2”/null

(8) months/null

(9) “you become”/ “she becomes”/ “he becomes”

(10) “your”/“her”/“his”

(11) “your”/“her”/“his”

(12) “you”/“her”/“him”

(13) “your”/“her”/“his”

FUGC01 Caption

Information About  (1)  Benefits

Fill-in:

(1) BGN plus BLN possessive/”Your”

FUG058 Suspension of Benefits Due to Outstanding Warrant

We cannot pay benefits to  (1)  because  (2)  an outstanding arrest warrant for a  (3)  .

Fill-ins:

(1) BGN plus BLN /you

(2) “she has”/“he has”/“you have”

(3) “felony crime”/”violation of a condition of probation or parole under Federal or State law”

FUG059 Warrant Information

Our records show that the  (1)   (2)   (3)  issued a warrant for  (4)  arrest for a felony crime or a violation of Federal or State probation or parole on  (5)  .

 (6) 

 (7)   (8) 

 (9)   (10) 

 (11)   (12) 

Social Security cannot provide further information about the warrant.

 (13)   (14)   (15) 

Fill-ins:

(1) Law Enforcement Agency Name

(2) Show the Address on FRATS that corresponds to Law Enforcement Agency Name. The address, if available, will be displayed as a single fill-in with commas after the street address, city, State, and zip./null

(3) Show the Law Enforcement Agency TELEPHONE NUMBER 10 by first showing the word “PHONE” followed by the phone number/null

(4) BGN plus BLN (possessive)/your

(5) Show the WARRANT ISSUE DATE in the format MM/DD/YYYY

(6) The warrant information we have is:/null

(7) Warrant Number:/null

(8) Show the WARRANT NUMBER/null

(9) Show the words “OCA Number:”/null

(10) Show the Originating Case Agency Number/null

(11) Show the words “NCIC NUMBER:”/null

(12) Show the National Crime Information Center Number/null

(13) Show the words “Please contact the”/null

(14) Law Enforcement Agency Name

(15) Show the word “directly.”/null

FUG060 Good Cause Reasons – No Time Limit

We will pay  (1)  if you contact us at any time and can show us that any of the following apply:

The warrant was issued incorrectly in  (2)  name because someone stole  (3)  identity. To prove this, submit a copy of the police report  (4)  filed as a victim of identity theft or another official document from the court or the warrant issuing agency stating that the warrant was erroneously issued in  (5)  name.

 (6)  found not guilty of the criminal offense. To prove this, submit a copy of the court docket indicating  (7)  found not guilty of the criminal charges or a copy of the court decision showing that  (8)  found not guilty of the criminal charges.

The underlying charges relating to the criminal offense were dismissed. To prove this, submit a copy of the court docket indicating charges were dismissed or another official court or law enforcement agency document stating that it dismissed the criminal charges.

The warrant for  (9)  arrest for the criminal offense was withdrawn. To prove this, submit a copy of the court docket or another official document from the issuing agency, indicating the warrant in question was withdrawn.

 (10)  otherwise cleared of the criminal offense. To prove this, submit a copy of the court docket or other court document indicating  (11)  cleared of the criminal charges.

Fill-ins:

(1) Beneficiary's Full name, no possessive/you

(2) “her”/“his”/“your”

(3) “her”/“his”/“your”

(4) “she”/“he”/“you”

(5) “her”/“his”/“your”

(6) “She was”/“He was”/“You were”

(7) “she was”/“he was”/“you were”

(8) “she was”/“he was”/“you were”

(9) ”her”/“his”/“your”

(10) “She was”/“He was”/“You were”

(11) “she was”/“he was”/“you were”

FUG061 Good Cause Reasons – Within 12 Months

If none of the above apply, we also may pay  (1)  benefits if you contact us within 12 months from the date of this letter and can show us that:

The crime for which the warrant was issued or the probation or parole violation was both nonviolent and not drug related and, if a probation or parole violation is involved, the original crime(s) for which  (2)  paroled or put on probation was both nonviolent and not drug related.

And

 (3)  neither been convicted of nor pled guilty to another felony crime since the date of the warrant.

And

The law enforcement agency that issued the warrant reports that it will not extradite  (4)  for the charges on the warrant or that it will not take action on the warrant for  (5)  arrest.

Or

The crime for which the warrant was issued or the probation or parole violation was both nonviolent and not drug related and, if a probation or parole violation is involved, the original crime[s] for which  (6)  paroled or put on probation was both nonviolent and not drug related.

And

 (7)  neither been convicted of nor pled guilty to another felony crime since the date of the warrant.

And

The only existing warrant was issued 10 or more years ago.

And

 (8)  medical condition impairs  (9)  mental capability to resolve the warrant; or  (10)  incapable of managing  (11)  benefits; or  (12)  legally incompetent; or Social Security has appointed a representative payee to handle  (13)  benefits or  (14)  residing in a long-term care facility, such as a nursing home or mental treatment/care facility.

Fill-Ins:

(1) Beneficiary's name, possessive/you

(2) “she was”/“he was”/“you were”

(3) “she has”/“he has”/“you have”

(4) “her”/“him”/“you”

(5) “her”/“his”/“your”

(6) “she was”/“he was”/“you were”

(7) “she has”/“he has”/“you have”

(8) “her”/“his”/“your”

(9) “her”/“his”/“your”

(10) “she is”/“he is”/“you are”

(11) “her”/“his”/“your”

(12) “she is”/“he is”/“you are”

(13) “her”/“his”/“your”

(14) “she is”/“he is”/“you are”

FWK001 Foreign Work Test Applies

If  (1)   (2)  working or if  (3)   (4)  45 hours or less in any month, please let us know right away because  (5)  may be eligible for benefits.

Fill-ins:

(1) “you”/“she”/“he”

(2) “stop”/“stops”

(3) “you”/“she”/“he”

(4) “work”/“works”

(5) “you”/“she”/“he”

GAR003 Garnishment Amount Withheld From PMA

We withheld  (1)  from  (2)  benefits due through  (3)  to pay  (4)  obligation for child support, alimony or court ordered victim restitution.

(1) Money amount

(2) FN possessive/“your”

(3) Date in format “June 2013”

(4) “her”/”his”/”your”

GAR004 Garnishment Ongoing Check Amount

Thereafter, we will withhold  (1)  from  (2)  benefit each month to pay  (3)  obligation for child support, alimony or court ordered victim restitution.

(1) Money amount

(2) FN possessive/“your”

(3) “her”/”his”/”your”

GAR007 Garnishment Withholding Stopped

We changed  (1)  payment to  (2)  beginning  (3)  because we are no longer withholding benefits to pay  (4)  obligation for child support, alimony or court ordered victim restitution.

(1) FN possessive/“your”

(2) Money amount

(3) date in format June 1991

(4) “her”/”his”/”your”

GAR064 Garnishment Amount Withheld From CMA

We withheld  (1)  from  (2)  next scheduled payment which is for  (3)  to pay  (4)  obligation for child support, alimony or court ordered victim restitution.

(1) Money amount

(2) FN possessive/“your”

(3) date in format June 1991

(4) “her”/”his”/”your”

GPOC01 Caption

Other Government Payments Affect Benefits

GPO001 Government Pension Offset (GPO) Explanation

We reduce the Social Security benefits we pay to  (1)  as a  (2)  when  (3)  a Federal, State, or local government pension. The pension must be based on work that is not covered by Social Security. We reduce benefits by two-thirds the amount of the pension. If the two-thirds amount is equal to or more than the Social Security monthly benefit, then we do not pay benefits. There are some exceptions to this rule. The enclosed factsheet, “Government Pension Offset,” explains this reduction in detail.

Fill-in:

(1) “you”/“him”/“her”

(2) “widow”/“widower”/“husband”/“wife”

(3) “you receive”/“he receives”/“she receives”

GPO002 GPO Reduction in Benefits

We are reducing  (1)  benefit beginning  (2)  because  (3)  eligible for a government pension.

Fill-ins:

(1) “your”/SN possessive

(2) date in format June 1991

(3) “you are”/“she is”/“he is”

HIBC01 Caption

Information About Medicare

HIBC05 Caption

Why  (1)  Cannot Qualify for Medicare

Fill-in:

(1) “You”/SN

HIBD01 Dictated Text

HIB001 Entitled to HI and/or SMI (This can also be an introductory statement (HIBI01))

 (1)  Medicare  (2)   (3)   (4)   (5)  .

Fill-ins:

(1) “Your”/FN

(2) “Part A (hospital insurance) starts”/ “Part B (medical insurance) starts”/ “Part A (hospital insurance) and Part B (medical insurance) start”

(3) Date in format June 2013

(4) “and Part B (medical insurance starts”

(5) Date in format June 2013

HIB002 New Medicare Card – PIC Change Conversion Award

We will send  (1)  a Medicare card.  (2)  should take this card with  (3)  when  (4)   (5)  medical care. If  (6)   (7)  medical care before receiving the card and  (8)  coverage has already begun, use this letter as proof that  (9)  covered by Medicare.

Fill-ins:

(1) Ms. plus BLN/Mr. plus BLN/BGN/BGN plus BLN/you

(2) “she”/“he”/“you”

(3) “her”/“him”/“you”

(4) “she”/“he”/“you”

(5) need/needs

(6) “she”/“he”/“you”

(7) need/needs

(8) “her”/“his”/“your”

(9) “she is”/“he is”/ “you are”

HIB003 Medicare Disallowance – Filed Before Initial Enrollment Period

 (1)  not entitled to  (2)  under Medicare because  (3)  application was filed too soon.  (4)  may apply again at any time during the period  (5)  through  (6)  .  (7)  must apply in the first three months of this period to make sure Medicare starts in the month  (8)   (9)  age 65.

Fill-ins:

(1) “you are”/“she is”/ “he is”

(2) “medical insurance coverage/medical or hospital insurance coverage”

(3) “your”/“her”/“his”

(4) “you”/“she”/“he”

(5) month and year

(6) month and year

(7) “you”/“she”/“he”

(8) “you”/“she”/“he”

(9) “reach”/“reaches”

HIB004 Medicare Disallowance – Not Timely Filed

 (1)  not entitled to  (2)  under Medicare because  (3)  application was filed too late.  (4)  should have filed before  (5)  . However,  (6)  may apply for coverage again during the next general enrollment period. A general enrollment period takes place in January, February, and March of each year.

Fill-ins:

(1) “you are”/“she is”/ “he is”

(2) “medical insurance coverage”

(3) “your”/“her”/“his”

(4) “you”/“she”/“he”

(5) month and year

(6) “you”/“she”/“he”

HIB005 SMI Premium Billing

 (1)  monthly premium for Medicare Part B (medical insurance) is  (2)  beginning  (3)   (4)   (5)  .

Fill-ins:

(1) “Your”/“His”/“Her”

(2) Amount of Part B premium in $$$$$.¢¢ format

(3) Date in MM CCYY format

(4) null/“and”/Null

(5) Show the unequal HSA amount that precedes the HSA amount in the format $$$/Show the EFD plus 1 month associated with the HSA amount in the format Month YYYY/ Show the most recent HSA amount in the format $$$/Show the EFD plus 1 month associated with the HSA amount in in the format Month YYYY (will be January plus appropriate YYYY/or other BRI month/YYYY)

HIB008 Premium Deductions

We will start to take premiums out of  (1)   (2)  check.

Fill-ins:

(1) “your”/“her”/“his”

(2) “next”/month, day and year

HIB009 SMI Premium Billing

We will send your first bill for the premiums within a month. Each bill will be for a 3-month period.

HIB010 SMI Premium Deductions Followed by Suspension

Because  (1)  monthly benefits are stopping, we will bill  (2)  every 3 months for the premiums.

Fill-ins:

(1) “your”/SN possessive/FN possessive/First Name possessive

(2) “you”/“her”/“him”

HIB011 HIB Premium Billing

The monthly premium for  (1)  hospital insurance is  (2)  . We will bill you each month for  (3)  .

Fill-ins:

(1) “your”/“her”/“his”

(2) “[2a] beginning [2b]/[2c] beginning [2d] and [2e] beginning [2f]

[2a] money amount/null

[2b] Month YYYY/null

[2c] money amount/null

[2d] Month YYYY/null

[2e] money amount/null

[2f] Month YYYY/null

(3) “this premium”/”the combined premium for hospital and medical insurance”

HIB013 Medicare Premium Penalty

 (1)  a penalty because  (2)  enrolled later than  (3)  could have.

Fill-ins:

(1) “This medical insurance premium includes”/“This hospital insurance premium includes”/“These hospital and medical insurance premiums include”

(2) “you”/“she”/“he”

(3) “you”/“she”/“he”

HIB014 State Buy-in

 (1)   (2)  will pay the premiums for  (3)  Medicare coverage  (4)  .

Fill-ins:

(1) “The State of”/null

(2) name of jurisdiction making payments

(3) “your”/“her”/“his”

(4) “in the future”/beginning [4a]

[4a] month and year

HIB015 Premiums Deducted from Civil Service Annuity

The Office of Personnel Management will deduct the medical insurance premiums from  (1)  annuity checks. They will let  (2)  know when this will start.

Fill-ins:

(1) “your”/“her”/“his”

(2) “you”/“her”/“him”

HIB019 Premium Hospital Insurance (HI)

 (1)  cannot get Medicare Part A (hospital insurance) for free. However,  (2)  may be able to buy Medicare Part A for  (3)  a month. Please contact us for more information

Fill-ins:

(1) “You”/FN

(2) “you”/“he”/“she”

(3) monthly premium HI amount

HIB020 Foreign Address

Normally Medicare will only pay for hospital and medical services which  (1)   (2)  in the United States.

Fill-ins:

(1) “you”/“she”/“he”

(2) “receive”/“receives”

HIB021 Subsequent Award – Medicare Not Affected

This letter does not affect  (1)  Medicare benefits.

Fill-in:

(1) “your”/“her”/“his”

HIB022 Coverage Transferred to Another Claim Number

 (1)  still be entitled to  (2)  insurance coverage from Medicare under the claim number we have shown above. We will send  (3)  a new Medicare card with this number on it.

Fill-ins:

(1) “You will”/“She will”/ “He will”

(2) “hospital”/“hospital and medical”

(3) “you”/“her”/“him”

HIBR30 Equitable Relief, Untimely Processing

We did not give  (1)  earlier medical insurance because we did not process it timely. If you want to have these benefits earlier, you can choose medical insurance benefits beginning  (2)  . If you want this benefit to start earlier, you must do the following things within 30 days after the date of this notice:

tell us in writing that you want medical insurance benefits beginning  (3)  ;

pay us $  (4)  . (this covers premiums due from  (5)  through  (6)  );or,

tell us we can withhold this amount from the check.

Fill-ins:

(1) “you”/FN

(2) Earlier SMI entitlement date *

(3) Earlier SMI entitlement date *

(4) Amount of SMI premium from earlier date *

(5) Earlier SMI entitlement date *

(6) Month prior to COM

(*) indicates that fill-in is manual

HIB031 Private Third Party Buy-in

Another individual or organization will pay the premiums for  (1)  Medicare coverage beginning  (2)  . Even though the bill will be sent to them, you are still responsible for seeing that  (3)  premiums are paid. If they decide that they will no longer send the payments, we will start to send the premium notices to you.

Fill-ins:

(1) “your”/SN possessive/FN possessive/First Name possessive

(2) month and year of buy-in

(3) “your”/SN possessive/FN possessive/First Name possessive

HIB032 SMI Option Presumed Refused, Puerto Rico

 (1)   (2)  eligible for medical insurance beginning  (3)  . If you want this coverage or need more information, you should contact your nearest Social Security office.

Fill-ins:

(1) “You”/SN/FN/First Name

(2) “are”/“is”

(3) date of entitlement to SMI - month and year

HIB035 SMI Deductions

We deduct medical insurance premiums from monthly benefit payments. If  (1)   (2)  benefit payments, we will not bill  (3)  for  (4)  premiums.

Fill-ins:

(1) “you”/“she”/“he”

(2) “receive”/“receives”

(3) “you”/“her”/“him”

(4) “your”/“her”/“his”

HIB037 Equitable Relief, Untimely Processing (Used Only with HIBR30)

If you want the benefits beginning  (1)  but find it hard to pay the premium amount in a lump sum, ask us about other ways to pay the money.

Fill-in:

(1) earlier SMI entitlement date - month and year

HIB038 Medicare Disallowance – Crime Against United States

 (1)  cannot qualify for Medicare because  (2)  been convicted of a crime against the security of the United States.

Fill-ins:

(1) “you”/“she”/“he”

(2) “you have”/“she has”/“he has”

HIB042 Claimant Could be or is Covered Under the Federal Employees Health Benefits Act of 1959

 (1)  cannot qualify for Medicare because  (2)  covered under the Federal Employees Health Benefits Act.

Fill-ins:

(1) “you”/“she”/“he”

(2) ““you are”/“she is”/“he is”/you could be/she could be/he could be”

HIB044 Not Entitled, Application Filed too Late

 (1)  not entitled to medical insurance coverage under Medicare because  (2)  application was filed too late.  (3)  should have filed before  (4)  . However,  (5)  may apply for coverage again during the next general enrollment period. A general enrollment period takes place in January, February and March of each year.

Fill-ins:

(1) “you are”/ “she is”/ “he is”

(2) “your”/ “her”/ “his”

(3) “you”/ “she”/ “he”

(4) age 65+4 months in format (“April 1992”)

(5) “you”/“she”/“he”

HIB050 Number Holder Age 65 Before End of Waiting Period

You do not qualify for Medicare based on disability because your coverage cannot start before you reach age 65.

To receive Medicare coverage before age 65, a person must be disabled under our rules for 29 months before coverage begins. Based on the date you said you became disabled, coverage could not begin until after you reach age 65. For this reason, we have not decided whether or not you are disabled.

You may qualify for Medicare when you reach age 65, whether or not you are disabled under our rules.

HIB051 Death Within 29 Months of Onset

To receive Medicare coverage before age 65, a person must qualify for disability benefits for 29 months before coverage begins. We were told that  (1)  became disabled on  (2)  , and died on  (3)  . Therefore  (4)  did not qualify for Medicare.

Fill-ins:

(1) NH Name

(2) onset date

(3) date of death - NH

(4) “she”/“he”

HIB052 SMIB Refusal Statement

If you do not want medical insurance, please complete the enclosed card and return it to us in the envelope we have provided. You will need to do this by the date shown on the card. If you decide you do not want the insurance, we will return any premiums that you have paid.

HIBR60 Prisoner Suspension

Generally, Medicare will not pay for hospital or medical items or services  (1)  while  (2)   (3)  . However, you may want to pay  (4)  Medicare medical insurance premiums for two reasons:

The premiums may be higher if you cancel the Medicare medical insurance now and re-enroll after  (5)  released from  (6)  .

 (7)  may not have medical insurance for a period of time after  (8)  released from  (9)  . This is because  (10)  will have to wait until a general enrollment period to re-enroll. A general enrollment period takes place in January, February and March of each year.

If you want to cancel  (11)  medical insurance, please let us know. If you decide to keep Medicare medical insurance, we will bill you for the premium. The first bill we send will be for a 3-month period and will be sent to you shortly before the payment is due.

Fill-ins:

(1) “you receive”/“FN receives”

(2) “you are”/“she is”/“he is”

(3) “imprisoned”/“confined in an institution” *

(4) “your”/“her”/“his”

(5) “you are”/“she is”/“he is”

(6) “prison”/“the institution” *

(7) “you”/“she”/“he”

(8) “you are”/“she is”/“he is”

(9) “prison”/“the institution” *

(10) “you”/“she”/“he”

(11) “your”/“her”/“his”

(*) indicates that the fill-in is manual

HIB062 Not Enrolling in SMI

 (1)   (2)  through  (3)  to sign up for Medicare Part B (medical insurance).

People who have Medicare Part B pay a monthly premium. If  (4)  not sign up for Part B when  (5)  first eligible,  (6)  may have to pay a late enrollment penalty for as long as  (7)  Part B.  (8)  monthly premium may go up 10 percent for each full 12-month period that  (9)  could have had Part B coverage, but did not sign up for it. Usually,  (10)  will not have to pay a late enrollment penalty if  (11)  up during a special enrollment period.

If  (12)  to sign up for Part B after  (13)  ,  (14)  will usually have to wait until the general enrollment period. The general enrollment period takes place in January, February, and March of each year. If  (15)  up in the general enrollment period,  (16)  Part B coverage will start July 1 of the year  (17)  up.

 (18)  may be able to get Part B in a special enrollment period if  (19)  all of these conditions:

  •  (20)  age 65 or older, and

  •  (21)  health insurance under an employer's group plan because  (22)  spouse currently works, and

  •  (23)  had health insurance coverage under that plan since  (24)  became age 65.

NOTE: COBRA and Retiree health coverage do not count as health insurance based on current employment.

 (25)  can sign up in a special enrollment period during these times:

  • At any time  (26)  coverage under that employer's group plan,

    or

  • During the 8 months after the work ends or  (27)  coverage under that plan ends, whichever occurs first.

Deciding when to sign up for Part B may depend on how  (28)  health insurance works with Medicare. For example, a group health plan is usually not the primary insurance if the employer has less than 20 employees. In this case, it is important to have Medicare coverage, and you may want to sign up now.

If  (29)  help deciding what to do, please contact  (30)  employee benefits office or contact us.

Fill-ins:

(1) “You”/FN

(2) “have”/“has”

(3) Date initial enrollment period ends (age 65 plus 3 months, in Month CCYY format)

(4) “you do”/“he does”/“she does”

(5) “you are”/“he is”/“she is”

(6) “you”/“he”/“she”

(7) “you have”/“he has”/“she has”

(8) “Your”/“His”/“Her”

(9) “you”/“he”/“she”

(10) “you”/“he”/“she”

(11) “you sign”/“he signs”/“she signs”

(12) “you want”/“he wants”/'she wants”

(13) Date initial enrollment period ends (age 65 plus 3 months, in Month CCYY format)

(14) “you”/“he”/“she”

(15) “you sign”/“he signs”/“she signs”

(16) “your”/“his”/“her”

(17) “you sign”/“he signs”/“she signs”

(18) “You”/“He”/“She”

(19) “you meet”/“he meets”/“she meets”

(20) “You are”/“He is”/“She is”

(21) “You have”/“He has”/“She has”

(22) “you or your”/“he or his”/“she or her”

(23) “You”/“He”/“She”

(24) “you”/“he”/“she”

(25) “You”/“He”/“She”

(26) “you or your spouse is working and you have”/ “he or his spouse is working and he has”/”she or her spouse is working and she has”

(27) “your”/“his”/“her”

(28) “your”/“his”/“her”

(29) “you need”/“he needs”/“she needs”

(30) “your”/“his”/“her”

HIB068 Equitable Relief

If  (1)  these benefits earlier,  (2)  can choose  (3)  insurance benefits beginning  (4)  . To start benefits earlier, within 60 days after the date of this notice  (5)  must tell us in writing that  (6)   (7)  insurance benefits beginning  (8)  . In addition,  (9)  must:

pay us  (10)  (this covers premiums due from  (11)  through  (12)  ); or

 (13) 

Fill-ins:

(1) “you want/she wants/he wants”

(2) “you”/“she”/“he”

(3) “hospital/medical/hospital and medical”

(4) HI or SMI NONEQRELST

(5) “you”/“she”/“he”

(6) “you want/she wants/he wants”

(7) “hospital/medical/hospital and medical”

(8) HI or SMI NONEQRELST

(9) “you”/“she”/“he”

(10) money amount (total premium(s) due for HI/SMI

(11) HI or SMI NONEQRELST

(12) date in format MM/YYYY

(13) tell us we can withhold this amount from the check/tell us to bill you for this amount.

HIB072 Medicare with Railroad Annuity Inv.

Since  (1)   (2)  a railroad beneficiary, the RRB will start to withhold medical insurance premiums from  (3)  Railroad Retirement annuity. If  (4)  not currently receiving a Railroad Retirement annuity, the Social Security Administration will let the RRB know when  (5)  next premium is due. The RRB will send  (6)  a bill for premiums.

Fill-ins:

(1) “you”/FN

(2) “are”/“is”

(3) “your”/“her”/“his”

(4) “you are”/“she is”/ “he is”

(5) “your”/“her”/“his”

(6) “you”/“her”/“him”

HIB074 New Medicare Card Issued

We will send  (1)  a new health insurance card. It will show that  (2)  entitled to  (3)  insurance.

Fill-ins:

(1) “you”/SN/FN/First Name

(2) “you are”/“she is”/ “he is”

(3) “hospital/medical/hospital and medical”

HIB075 Equitable Relief

If  (1)  benefits beginning  (2)  but  (3)  it hard to pay the premium amount in a lump sum, ask us about other ways to pay the money.

Fill-ins:

(1) “you want/she wants/he wants”

(2) show the HI/SMI NONEQRELST date in format “July 1999”

(3) “find”/“finds”

HIB090 Medicare Terminates, Destroy Card

 (1)  Medicare card will no longer be valid when  (2)   (3)  coverage ends. Please destroy  (4)  card after  (5)  coverage ends.

Fill-ins:

(1) null plus FN possessive/“Your”

(2) “his”/“her”/“your”

(3) “Medicare Part A (hospital insurance) and Part B (medical insurance)”/”Medicare Part B (medical insurance)”/”Medicare Part A (hospital insurance)”

(4) “his”/“her”/“your”

(5) “his”/“her”/“your”

HIB094 Entitlement Conversion, No Change in HI/SMI

The decision on  (1)   (2)  benefits does not affect  (3)   (4)  coverage.

Fill-ins:

(1) “your”/SN possessive/FN possessive/First Name possessive

(2) “retirement”/“disability”

(3) “your”/“her”/“his”

(4) “hospital insurance/medical insurance/hospital and medical insurance”

HIB095 Earlier HI/SMI Dates

We have changed the date of  (1)  entitlement to  (2)  under Medicare.  (3)  new entitlement date is  (4)  . We will take any premiums due for the insurance out of  (5)  next payment.

Fill-ins:

(1) “your”/SN possessive

(2) “hospital insurance/medical insurance/hospital and medical insurance”

(3) “your”/“her”/“his”

(4) current HI/SMI date of entitlement in format “July 1999”

(5) “your”/“her”/“his”

HIB096 RRB Cert Beneficiary Entitled to HI/SMI

 (1)  entitled to Medicare. The Railroad Retirement Board (RRB) has jurisdiction of  (2)  Medicare. RRB will issue  (3)  Medicare card. If  (4)  not receive  (5)  Medicare card in 45 days, you should contact the local office of the Railroad Retirement Board.

Fill-ins:

(1) “she is”/ “he is”/ “you are”

(2) “her”/“his”/ “your”

(3) “her”/“his”/“your”

(4) “She does”/“He does”/“You do”

(5) “her”/“his”/“your”

HIB103 Third Party Buy-in, Closed Period

 (1)   (2)  paid  (3)  Medicare  (4)  insurance premium for  (5)  .

Fill-ins:

(1) The State of/null

(2) state or territory in the format “Washington, D.C.”/“The Virgin Islands”/“Maryland” or “Guam”

(3) “your”/SN possessive

(4) “hospital/medical/hospital and medical”

(5) date(s), in format “Month YYYY” or “Month YYYY and Month YYYY” or “Month YYYY through Month YYYY”

HIB108 Third Party, Group Payer – Billing Terminates

The organization that was paying  (1)  Medicare  (2)  insurance premium will no longer pay it after  (3)  .  (4)  must pay the premium beginning  (5)  .

Fill-ins:

(1) “your”/SN possessive/FN possessive/First Name possessive

(2) “hospital/medical/hospital and medical”

(3) date in format “MM/YYYY”

(4) “you”/“she”/“he”

(5) date in format “MM/YYYY”

HIB119 Third Party, Group Payer – Confirmation of Billing Arrangement

 (1)  recently arranged for an organization to pay  (2)  Medicare  (3)  insurance premium. Although we will send the bills to this organization,  (4)  responsible for seeing that they are paid.

If this organization decides to stop paying  (5)  premium, we will again send the bills to  (6)  .

If there is any other change in  (7)  Medicare premium, we will let  (8)  know.

Fill-ins:

(1) “You”/SN possessive/FN possessive/First Name possessive

(2) “your”/“her”/“his”

(3) “hospital/medical/hospital and medical”

(4) “you are”/“she is”/“he is”

(5) “your”/“her”/“his”

(6) “you”/“her”/“him”

(7) “your”/SN possessive

(8) “you”/“her”/“him”

HIB121 ESRD Awards (Introductory Paragraph)

We are writing to tell you that  (1)  entitled to Medicare coverage because of  (2)  kidney condition.

Fill-ins:

(1) NHFN plus “is”/you are

(2) “your”/“her”/“his”

HIB122 Entitlement Conversion Cases with Previous HI and/or SMI

 (1)  already entitled to  (2)  because  (3)   (4)  . The date[s] of  (5)  entitlement to  (6)  did not change.

Fill-ins:

(1) “You are”/SN plus “is”

(2) “hospital insurance/medical insurance/hospital and medical insurance”

(3) “you are”/“he is”/“he is”

(4) disabled/over age 65/enrolled based on a kidney condition

(5) “your”/“her”/“his”

(6) “hospital insurance/medical insurance/hospital and medical insurance”

HIB124 Awards – Previous SMI

However,  (1)  now  (2)  hospital insurance beginning  (3)  .

Fill-ins:

(1) “you”/“she”/“he”

(2) “has”/“have”

(3) current HI date of entitlement in format “July 1999”

HIB125 DIB Awards, Beneficiary Previously Entitled to HI/SMI Based on ESRD

If  (1)  disability ends,  (2)  may still qualify for Medicare because of  (3)  kidney condition if:

 (4)  disability ends less than 12 months after  (5)  last regular dialysis, or

 (6)  disability ends less than 36 months after  (7)  last kidney transplant.

Fill-ins:

(1) “your”/“her”/“his”

(2) “you”/“she”/“he”

(3) “your”/“her”/“his”

(4) “your”/“her”/“his”

(5) “your”/“her”/“his”

(6) “your”/“her”/“his”

(7) “your”/“her”/“his”

HIB126 ESRD Awards, Beneficiary Previously Receiving Premium HI

 (1)  will no longer have to pay premiums for hospital insurance.

Fill-in:

(1) “You”/SN

HIB127 ESRD Awards, Beneficiary Previously Receiving Premium HI

But,  (1)  will still have to pay premiums for medical insurance. The monthly medical insurance premium rate is $  (2)  .

Fill-ins:

(1) “you”/“she”/“he”

(2) [2a] beginning [2b]./[2c] beginning [2d] and $[2e] beginning [2f]

[2a] money amount

[2b] date, in format “Month YYYY”

[2c] money amount

[2d] date, in format “Month YYYY”

[2e] money amount

[2f] date, in format “Month YYYY”

HIB128 ESRD Awards

Medicare coverage based on  (1)  kidney condition will end the last day of the  (2)  month after the month  (3)   (4)  unless before then  (5)  again:

get(s) a kidney transplant, or

begin(s) regular dialysis.

Fill-ins:

(1) “your”/“her”/“his”

(2) 12th/36th

(3) “you”/“she”/“he”

(4) got your transplant/got her transplant/got his transplant/stops dialysis/stop dialysis

(5) “you”/“she”/“he”

HIB129 ESRD Awards, Previous Premium HI or SMI

Even if  (1)  no longer entitled to free hospital insurance based on  (2)  kidney condition,  (3)  will still be entitled to Medicare because  (4)   (5)  .

Fill-ins:

(1) “you are”/“she is”/ “he is”

(2) “your”/“her”/“his”

(3) “you”/“she”/“he”

(4) “you are”/“she is”/”he is”

(5) over age 65/disabled/a Railroad Retirement board beneficiary

HIB130 Closed Period ESRD Award

Our records show that  (1)   (2)  in  (3)  . Therefore,  (4)  Medicare coverage based on  (5)  kidney condition ends the last day of  (6)  .

Fill-ins:

(1) “you”/“she”/“he”

(2) “stopped regular dialysis”/“received a kidney transplant”

(3) date in the format “July 1999”

(4) “your”/“her”/“his”

(5) “your”/“her”/“his”

(6) date in the format “July 1999”

HIB132 Closed Period Award for RRB Beneficiary

However, since the Railroad Retirement Board [RRB] handles  (1)  hospital and medical insurance  (2)  Medicare coverage will continue unless the RRB tells  (3)  they are stopping  (4)  coverage.

Fill-ins:

(1) “your”/“her”/“his”

(2) “your”/“her”/“his”

(3) “you”/“her”/“him”

(4) “your”/“her”/“his”

HIB136 ESRD Closed Period Awards

Let us know right away if  (1)  regular dialysis again or  (2)  a kidney transplant so  (3)  can file a new claim for Medicare coverage based on  (4)  kidney condition.

Fill-ins:

(1) “you resume”/“she resumes”/“he resumes”

(2) “get”/“gets”

(3) “you”/“she”/“he”

(4) “your”/“her”/“his”

HIB151 Closed Period Third Party Buy-in

 (1)  must pay the premium beginning  (2)  .

Fill-ins:

(1) “you”/“she”/“he”

(2) date, in format “Month YYYY”

HIB152

 (1)   (2)  through  (3)  to enroll in Medicare Part B (medical insurance).

People who have Part B pay a monthly premium. If  (4)  not sign up for Part B when  (5)  first eligible,  (6)  may have to pay a late enrollment penalty for as long as  (7)  Part B.  (8)  monthly premium may go up 10 percent for each full 12-month period that  (9)  could have had Part B coverage, but did not sign up for it. Usually,  (10)  will not have to pay a late enrollment penalty if  (11)  up during a special enrollment period.

If  (12)  to sign up for Part B after  (13)  ,  (14)  will usually have to wait until the general enrollment period. The general enrollment period takes place in January, February, and March of each year. If  (15)  up in the general enrollment period,  (16)  Part B coverage will start July 1 of the year  (17)  up.

 (18)  may also be able to sign up during a special enrollment period.  (19)  can do this if  (20)  one of the conditions listed below:

  •  (21)  covered under a group health plan through  (22)  current work or  (23)  spouse's current work,

  •  (24)  covered under a large group health plan through  (25)  current work or any family member's current work.

 (26)  may sign up for medical insurance at any time  (27)  covered under the group health plan. However,  (28)  may wait and sign up during the 8-month period that begins when the work ends or  (29)  coverage under the plan ends, whichever occurs first.  (30)  may also sign up if the type of plan  (31)  changes.

NOTE: COBRA and Retiree health coverage do not count as health insurance based on current employment.

Deciding when to sign up for Part B may depend on how  (32)  health insurance works with Medicare. For example, a group health plan is usually not the primary insurance if the employer has less than 20 employees. In this case, it is important to have Medicare coverage, and you may want to sign up now.

If  (33)  help deciding what to do, please contact  (34)  employee benefits office or contact us.

Fill-ins:

(1) FN/“You”

(2) “have”/“has”

(3) Hospital Insurance Start Date (HI-START) plus 3 months in Month CCYY format

(4) “you do”/“he does”/“she does”

(5) “you are”/“he is”/“she is”

(6) “you”/“he”/“she”

(7) “you have”/“he has”/“she has”

(8) “Your”/“His”/“Her”

(9) “you”/“he”/“she”

(10) “you”/“he”/“she”

(11) “your sign”/“he signs”/“she signs”

(12) “your want”/“he wants”/“she wants”

(13) Hospital Insurance Start Date (HI-START) plus 3 months in Month CCYY format

(14) “you”/”he”/”she”

(15) “your sign”/”he signs”/”she signs”

(16) “your”/”his”/”her”

(17) “you sign”/”he signs”/”she signs”

(18) FN / “You”

(19) “You”/”He”/”She”

(20) “you meet”/”he meets”/”she meets”

(21) “You are”/”He is”/”She is”

(22) “your”/”his”/”her”

(23) “your”/”his”/”her”

(24) “You are”/”He is”/”She is”

(25) “your”/”his”/”her”

(26) “You”/”He”/”She”

(27) “you are”/”he is”/”she is”

(28) “you”/”he”/”she”

(29) “your”/”his”/”her”

(30) “You”/”He”/”She”

(31) “you have”/”he has”/”she has”

(32) “your”/”his”/”her”

(33) “you need”/”he needs”/”she needs”

(34) “your”/”his”/”her”

HIB157

If this notice is for a child under age 19 who is not covered by health insurance, there is a Children's Health Insurance Program that may help. To find out more, you can look on the Internet at  (1)  or call, toll free, 1-877-KIDS-NOW

(1-877-543-7669). The number connects you to your state program.

HIB170 ESRD, Monthly Benefits Terminating but HI/SMI Continuing

Even though  (1)  no longer receiving monthly checks,  (2)  will still have hospital and medical insurance coverage under Medicare. Please keep  (3)  Medicare card.

There is a monthly premium for  (4)  medical insurance. Because we are stopping monthly checks, we will bill  (5)  every 3 months for the premiums.

Fill-ins:

(1) “you are”/SN plus “is”

(2) “you”/“she”/“he”

(3) “your”/“her”/“his”

(4) “your”/“her”/“his”

(5) “you”/“her”/“him”

HIB171 ESRD, Monthly Benefits Terminating but HI/SMI with State Buy-in is Continuing

Even though  (1)  no longer receiving monthly checks,  (2)  will still have hospital and medical insurance coverage under Medicare. Please keep  (3)  Medicare card. The State where  (4)  will continue to pay the premiums for  (5)  medical insurance coverage under Medicare.

Fill-ins:

(1) “you are”/SN plus “is”

(2) “you”/she”/“he”

(3) “your”/“her”/“his”

(4) “you live/she lives/he lives”

(5) “your”/“her”/“his”

HIB186 Information Regarding Income Related Monthly Adjustment Amount (IRMAA)

IMPORTANT: A new law changes how premiums for Medicare Part B are calculated for some higher income beneficiaries, generally individuals with incomes higher than  (1)  and couples with incomes higher than  (2)  . Social Security will be contacting the Internal Revenue Service, and if we determine that  (3)  to pay a higher premium, we will send  (4)  a notice explaining our decision, and the higher amount will be effective  (5)  . For more information, visit www.socialsecurity.gov on the Internet or call us toll-free at 1-800-772-1213 (TTY 1-800-325-0778).

Fill-ins:

(1) Show the IRMAA level 1 yearly amount for singles

(2) Show the IRMAA level 1 yearly amount for couples

(3) “he has”/“she has”/ “you have”

(4) “her”/”him”/”you”

(5) SMI start date in format July 2013

HIB215 Closed Period DIB Award and HI/SMI Terminates

Since  (1)  no longer entitled to monthly Social Security benefits, we are stopping  (2)   (3)  insurance coverage under Medicare.  (4)   (5)  insurance coverage ends on the last day of  (6)  . Please destroy  (7)  Medicare card after the coverage ends.

Fill-ins:

(1) “you are”/“she is”/ “he is”

(2) “your”/“her”/“his”

(3) “hospital and medical”/“hospital”

(4) “your”/“her”/“his”

(5) “hospital and medical”/“hospital”

(6) HI termination date in the format May 1999

(7) “your”/“her”/“his”

HIB249 SMI Equitable Relief and Retroactive VSMI Exists

If you want your medical insurance to start earlier, you can choose to have it start in  (1)  . To start your medical insurance earlier, you must do the following things within 60 days after the date of this notice:

  • tell us in writing that you want medical insurance beginning  (2)  ;

    • AND

  • pay us  (3)  or tell us we can withhold this amount from your check. This amount covers the premiums due from  (4)  through  (5)  .

If you would find it hard to pay the premium amount you would owe in a lump sum, ask us about other ways to pay the premium.

If you choose to have your medical insurance start in  (6)  , your current monthly premium will be  (7)  . If you do not choose the earlier date, your monthly premium will be  (8)  .

(1) date in format July 2013

(2) date in format July 2013

(3) Money amount

(4) date in format July 2013

(5) date in format July 2013

(6) date in format July 2013

(7) Money amount

(8) money amount

IDN016 Proof of Identity Not Provided

We cannot approve  (1)  claim because  (2)  did not give us proof of  (3)  identity.  (4)  responsible for providing evidence to support  (5)  claim.

Fill-ins:

(1) “your”/”BN, possessive”

(2) “you”/“he”/“she”

(3) “your”/ “his”/”her”

(4) “You are”/”BN is”

(5) “your”/ “his”/”her”

INFC02 Caption

Your Responsibilities

INFC03 Caption

What You Need To Do

INFC07 Caption

Things To Remember For The Future

INFC09 Caption

Rules For Lawful Presence In The U.S.

INFD02 Dictated Text

INFD07 Dictated Text

INS010 Number Holder Not Insured

 (1)  did not work long enough under Social Security for  (2)  to receive benefits.

Work under Social Security is figured in credits. Please read the enclosed pamphlet, “How You Earn Social Security Credits,” which explains how the credits are earned and how many a person needs to receive benefits.

For  (3)  to qualify for benefits,  (4)  needed to have earned:

a total of  (5)  credits, or

at least 6 credits in the period beginning  (6)  .

 (7)  earned a total of only  (8)  credits and only  (9)  credits in the period beginning  (10)  . These figures are based on  (11)   (12)  date of birth,  (13)  and  (14)   (15)  date of death,  (16)  .

Fill-ins:

(1) NH's FN

(2) “you”/“her”/“him”

(3) “you”/SN/FN/First Name

(4) NH's FN

(5) QCR in format 40

(6) 36 months from NH's DOD and enter month and year of first month in the quarter in the format May 1944

(7) “She/He”

(8) QCE in format 10

(9) total numeric value of credits earned for period determined in fill-in 6

(10) Same as fill-in 6

(11) “her”/“his””

(12) “corrected”/null

(13) NH birthdate in format July 10, 1999

(14) “her”/“his”

(15) “corrected”/null

(16) NH date of death in format July 24, 1999

INS011 Number Holder Uninsured Survivor Disallowance (D/F Only)

 (1)  did not work long enough under Social Security for  (2)  to receive benefits.

Work under Social Security is figured in credits. Please read the enclosed pamphlet, “How You Earn Social Security Credits,” which explains how the credits are earned and how many a person needs to receive benefits.

For  (3)  to qualify for benefits,  (4)  needed to have earned  (5)  credits.  (6)  earned  (7)  credits. These figures are based on  (8)   (9)  date of birth,  (10)  and  (11)   (12)  date of death,  (13)  .

Fill-ins:

(1) NH's FN

(2) “you”/“her”/“him”

(3) “you”/SN/FN/First Name

(4) NH's FN

(5) QCR in format 40

(6) “She”/“He”

(7) QCE in format 10

(8) “her”/“his”

(9) “corrected”/null

(10) NH's birth date in format July 10, 1999

(11) “her”/“his”

(12) “corrected”/null

(13) NH's date of death in format July 24, 1999

INS012 Claimant Uninsured for Medicare

 (1)  did not work long enough under Social Security to qualify for Medicare.

Work under Social Security is figured in credits. Please read the enclosed pamphlet, “How You Earn Social Security Credits,” which explains how the credits are earned.

For  (2)  to qualify for Medicare,  (3)  needed to have earned  (4)  credits.  (5)  earned  (6)  credits. These figures are based on  (7)   (8)  date of birth,  (9)  .

Fill-ins:

(1) NH's FN

(2) SN

(3) NH's SN

(4) required QC's in format 40

(5) She/He

(6) earned QC's in format 10

(7) NH's SN possessive

(8) correct/null

(9) NH's birth date in format mm/dd/yy.

INS014 Auxiliary (Life) Claim Disallowed – Number Holder Uninsured

 (1)  did not work long enough under Social Security for  (2)  to receive benefits.

Work under Social Security is figured in credits. Please read the enclosed pamphlet, “How You Earn Social Security Credits,” which explains how the credits are earned and how many a person needs to receive benefits.

For  (3)  to qualify for benefits,  (4)  needed to have earned  (5)  credits.  (6)  earned  (7)  credits. These figures are based on  (8)   (9)  date of birth,  (10)  .

Fill-ins:

(1) NH's FN

(2) “you”/“her”/“him”

(3) “you”/beneficiary's SN/FN/First Name

(4) NH's FN

(5) QCR in format 40

(6) “She”/“He”

(7) QCE in format 10

(8) “her”/“his”

(9) “corrected”/null

(10) NH's date of birth

INS015 LSDP Disallowance – Number Holder Not Insured

 (1)  did not work long enough under Social Security for  (2)  to qualify for the lump sum death payment.

For  (3)  to qualify for the lump sum death payment,  (4)  needed to have earned:

a total of  (5)  credits, or

at least 6 credits in the period beginning  (6)  .

 (7)  earned a total of only  (8)  credits and only  (9)  credits in the period beginning  (10)  . These figures are based on  (11)   (12)  date of birth,  (13)  and  (14)   (15)  date of death,  (16)  .

Fill-ins:

(1) NH's FN

(2) “you”/FN

(3) “you”/FN

(4) NH's SN

(5) QCR in format 40

(6) Subtract 36 months from NH's DOD and enter first month and year of quarter

(7) “She”/“He”

(8) QCE in format

(9) Total numeric value of credits earned during period determined in fill-in (6)

(10) same as fill-in (6)

(11) “her”/“his”

(12) “corrected”/null

(13) NH birth date

(14) “her”/“his”

(15) “corrected”/null

(16) NH date of death

INS016 Number Holder Uninsured – Medicare (Individual Other Than Number Holder Filed)

 (1)  did not work long enough under Social Security for  (2)  to qualify for Medicare.

Work under Social Security is figured in credits. Please read the enclosed pamphlet, “How You Earn Social Security Credits,” which explains how the credits are earned.

For  (3)  to qualify for Medicare,  (4)  needed to have earned a total of  (5)  credits.

 (6)  earned a total of  (7)   (8)  and still needs  (9)  more. These figures are based on  (10)  date of birth,  (11)  .

Fill-ins:

(1) NH's FN

(2) “you”/FN

(3) “you”/“her”/“him”

(4) NH's SN

(5) quarters needed in the format “40”

(6) NH's SN

(7) quarters earned in the format “40”

(8) “credit”/“credits”

(9) additional quarters needed

(10) NH's SN possessive

(11) NH's date of birth

INS020 Expiration of Disability Insured Status

We consider  (1)  disabled under our rules, if  (2)  a medical condition that:

  • keeps  (3)  from doing any type of substantial gainful work, and

  • has lasted or is expected to last for at least 12 months in a row or result in death.

  •  (4)  also must have earned enough credit for work under Social Security.

  • The last date when  (5)  had enough credits is  (6)  . We did not find that  (7)  disabled before this date.

Please read the enclosed pamphlet, “How You Earn Credits,” which tells you how to earn credits and how many credits  (8)  to get benefits.

Fill-ins:

(1) “you”/FN

(2) “you have”/“he has”/ “she has”

(3) ”you”/“him”/“her”

(4) “You”/FN

(5) “you”/“he”/“she”

(6) Date last insured in format MM, YYYY

(7) “you were”/“he was”/ “she was”

(8) “you need”/“he needs”/ “she needs”

INS021 Disallowance – Not Insured

 (1)   (2)  not worked long enough under Social Security to receive benefits  (3)  .

Work under Social Security is figured in credits. Please read the enclosed pamphlet, “How You Earn Social Security Credits,” which explains how the credits are earned and how many a person needs to receive benefits.

To qualify for benefits,  (4)   (5)  a total of  (6)  work credits.  (7)   (8)  earned  (9)  credits, and still  (10)   (11)   (12)  more. These figures are based on  (13)   (14)   (15)  .

Fill-ins:

(1) “You”/NH SN

(2) “have”/“has”

(3) “on your own record”/“on her own record”/“on his own record”

(4) “you”/“she”/“he”

(5) “need”/“needs”

(6) required QCs

(7) “you”/“she”/“he”

(8) “have”/“has”

(9) earned QCs

(10) “need”/“needs”

(11) quarters still needed

(12) “credit”/“credits”

(13) “your”/NH's FN possessive

(14) “corrected date of birth”/“date of birth”/null

(15) NH's date of birth

ISCH01 Heading

Payment Summary

LIS003 Claimant Dies In or Before DIB Waiting Period

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

(1) “your”

LSP003 LSDP Disallowance – Eligible Spouse was Living in the Same Household as the Number Holder

 (1)  not qualify for the lump-sum death payment because we are paying it to  (2)   (3)  . Since  (4)  was living with  (5)  when  (6)  died,  (7)  qualifies for the payment.

Fill-ins:

(1) You do/beneficiary's SN plus “does”/beneficiary's FN plus “does”/beneficiary's First Name plus “does”

(2) NH-FN possessive

(3) “widow”/“widower”

(4) “she”/“he” (refers to surviving “widow”/ “widower”)

(5) NH's SN

(6) “she”/“he” (refers to NH)

(7) “she”/“he” (refers to surviving “widow”/ “widower”)

LSP004 LSDP Disallowance – Child Beneficiary Meets Requirements but Eligible Widow(er) Survivor Exists

 (1)  not qualify for the lump-sum death payment because we are paying it to  (2)   (3)  . Since  (4)  was living with  (5)  when  (6)  died, or entitled to benefits on  (7)  record for the month of death,  (8)  qualifies for the payment.

Fill-ins:

(1) “You do”/beneficiary's First Name plus “does”/beneficiary's FN plus “does”

(2) NH-FN possessive

(3) “widow”/“widower”

(4) “she”/“he” (refers to the “widow”/”widower”)

(5) NH's SN

(6) “she”/“he” (refers to the NH)

(7) “her”/“his” (refers to the NH)

(8) “she”/“he” (refers to the surviving “widow”/”widower”)

LSP007 LSDP Disallowance – Surviving Spouse

 (1)  not qualify for the lump-sum death payment as a surviving spouse on  (2)  Social Security record. To qualify  (3)  must have been living with  (4)  at the time of  (5)  death or eligible for regular Social Security benefits on  (6)  record.

The facts we have do not show that either of these requirements is met.

Fill-ins:

(1) “You do”/“She does”/ “He does”

(2) NH FN possessive

(3) “you”/“she”/ “he”

(4) NH SN

(5) “her”/“his”

(6) “her”/“his”

LSPR08 LSDP Disallowance – Outside U.S. and not U.S. Citizen

 (1)  not qualify for the lump-sum death payment because  (2)  :

was not a United States citizen, and

died outside the U.S., and

was not able to receive benefits because  (3)  was outside the U.S.

Fill-ins:

(1) “You do”/“She does”/“He does”

(2) FN of NH

(3) “she”/“he”

LSP009 LSDP Disallowance

 (1)  not qualify for the lump-sum death payment because  (2)  not  (3)   (4)  or child.

Fill-ins:

(1) “You do”/“She does”/“He does”

(2) “you are”/“she is”/“he is”

(3) NH's FN possessive

(4) “widow”/“widower”

LSP011 LSDP Disallowance – Not Within Time Limit

 (1)  not qualify for the lump-sum death payment because  (2)  did not apply for it within 2 years of  (3)  death. Our records show that  (4)  died on  (5)  and that  (6)  applied on  (7)  .

Fill-ins:

(1) “You do”/“She does”/ “He does”

(2) “you”/“she”/“he”

(3) NH's FN possessive

(4) “she”/“he”

(5) NH's date of death

(6) “you”/FN

(7) CL application date

LSP012 LSDP Disallowance - Child

 (1)  not qualify for the lump-sum death payment as a child on  (2)  Social Security record. To qualify,  (3)  must have been eligible for regular Social Security benefits on  (4)  record at the time of  (5)  death.

Fill-ins:

(1) “You do”/ “She does”/ “He does”

(2) NH's FN possessive

(3) “you”/“she”/“he”

(4) NH's SN possessive

(5) “her”/“his”

LSP013 Child Awarded Share of LSDP Along with Another Child(ren)

There are  (1)  children who were eligible for benefits on  (2)  Social Security record in the month  (3)  died. Each child is due an equal share of the lump-sum death payment. The amount we have shown above is  (4)  share.

Fill-ins:

(1) enter number of PICs in format “two”

(2) Number holder's FN possessive

(3) “she”/“he”

(4) FN possessive/“your”

MARD01 Dictated Text

MAR001 Disallowance - Divorce

To qualify for benefits as a divorced  (1)  ,  (2)  must meet one of these requirements:

  •  (3)  and  (4)  must have been married under the laws of  (5)  , where  (6)  lived when  (7)  , or

  •  (8)  the same rights as a spouse to inherit from  (9)  under the laws of  (10)  .

The facts we have do not show that either requirement is met.

Fill-ins:

(1) “widow”/“widower”/“wife”/“husband”/“mother”/“father”/“disabled widow”/“disabled widower”

(2) “you”/“she”/“he”

(3) You/SN

(4) NH's FN

(5) State name of residence at time of death or time of filing

(6) NHs SN

(7) “[7a] died”/“[7b] applied for benefits”

[7a] “she”/“he”

[7b] “you”/SN

(8) “you have”/ “she has”/”he has”

(9) NHs SN

(10) same as fill-in (5)

MARD02 Dictated Text

MAR002 Disallowance – Marriage not Valid

To qualify for benefits as a  (1)  ,  (2)  must meet one of these requirements:

  •  (3)  and  (4)  must  (5)  married under the laws of  (6)  , where  (7)  lived when  (8)  , or

  •  (9)  went through a ceremony which  (10)  thought resulted in a legal marriage with  (11)  and  (12)  still living with  (13)  when  (14)  , or

  •  (15)  the same rights as a spouse to inherit from  (16)  under the laws of  (17)  .

The facts we have do not show that any of these requirements is met.

Fill-ins:

(1) “wife”/“husband”/“widow”/“widower”/“mother”/“father”/“disabled widow”/“disabled widower”

(2) “you”/“she”/“he”

(3) “you”/SN

(4) NH's FN

(5) “have been”/“be”

(6) State name

(7) NH's SN

(8) “[8b] died”/“[8a] applied for benefits”

[8a] “she/he”

[8b] “you”/“she”/“he”

(9) “you”/SN

(10) “you”/“she”/“he”

(11) NH's SN

(12) “you were”/“she was”/“he was”

(13) “her/him”

(14) “PN died”/“PN applied for benefits”

[14a] “she/he”

[14b] “you”/“she”/“he”

(15) SN has/you have

(16) NH's SN

(17) State name

MAR007 Disallowance Due to Remarriage – Widow(er)

To qualify for benefits as a  (1)  ,  (2)  must meet one of these requirements:

 (3)  not married now, or

 (4)  remarried after age 60, or

 (5)  remarried after age 50 while  (6)  entitled to benefits as a disabled  (7)  .

The facts we have do not show that any of these requirements is met.

Fill-ins:

(1) “widow”/“widower”

(2) “you”/“she”/”he”

(3) “you are”/ “she is”/“he is”

(4) “you”/“she”/“he”

(5) “you”/”she”/”he”

(6) “you were”/“she was”/ “he was”

(7) “widow”/“widower”

MAR010 Disallowance – Child Married

 (1)  not qualify for child's benefits because  (2)  married.

Fill-ins:

(1) “You do”/“She does”/ “He does”

(2) “you are”/“she is”/ “he is”

MAR011 Disallowance – Parent Married

 (1)  not qualify for parent's benefits because  (2)  married after  (3)  death.

Fill-ins:

(1) “You do”/ “She does”/”He does”

(2) “you”/“she”/ “he”

(3) NH FN possessive

MARR12 Medicare Disallowance – Divorced Spouse

To qualify for Medicare as a divorced  (1)  ,  (2)  must meet one of these requirements:

 (3)  and  (4)  must have been married under the laws of  (5)  , where  (6)  lived when  (7)  , or

 (8)  the same rights as a spouse to inherit from  (9)  under the laws of  (10)  .

The facts we have do not show that either requirement is met.

Fill-ins:

(1) “wife”/“husband”

(2) “you”/“she”/“he”

(3) “you”/“she”/“he”

(4) NH's FN

(5) State name *

(6) NH's SN

(7) “she died”/“he died”/“she applied for Medicare”/“he applied for Medicare”/“you applied for Medicare”

(8) “you have”/“she has”/“he has”

(9) NH's SN

(10) State name

(*) indicates that the fill-in is manual

MARR13 MEDICARE DISALLOWANCE - MARRIAGE

To qualify for Medicare as a  (1)  ,  (2)  must meet one of these requirements:

 (3)  and  (4)  must  (5)  married under the laws of  (6)  , where  (7)  lived when  (8)  , or

 (9)  went through a ceremony which  (10)  thought resulted in a legal marriage with  (11)  and  (12)  still living with  (13)  when  (14)  , or

 (15)  the same rights as a spouse to inherit from  (16)  under the laws of  (17)  .

The facts we have do not show that any of these requirements is met.

Fill-ins:

(1) “widow”/“widower”/“wife”/“husband”

(2) “you”/“she”/“he”

(3) “you”/“she”/ “he”

(4) NH's FN

(5) “have been”/“be”

(6) State name *

(7) NH's SN

(8) “she died”/”he died”/”she applied for Medicare”/”he applied for Medicare”/”you applied for Medicare”

(9) “you”/“she”/“he”

(10) “you”/“she”/“he”

(11) NH's SN

(12) “you were”/ “she was”/ “he was”

(13) “her”/“him”

(14) “she died”/”he died”/ “she applied”/ “he applied”/ “you applied”

(15) “you have”/“she has”/“he has”

(16) NH's SN

(17) State name *

(*) indicates that the fill-in is manual

MAR014

 (1)  not qualify for Medicare as  (2)   (3)  because  (4)  earlier marriage was never ended.

Fill-ins:

(1) “You do”/ “He does”/ “She does”

(2) NH Name (possessive)

(3) “widow”/ “widower”

(4) “your”/“his”/ “her”

MARD24 Dictated Text

MAR024 Disallowed Mother/Father - Claimant has Re-married

To qualify for  (1)  benefits,  (2)  must:

not be married now, or

be married to someone who is entitled to Social Security benefits.

 (3)  not qualify because  (4)  married a person who was not entitled to Social Security benefits, and  (5)  marriage has not ended.

Fill-ins:

(1) “mother's”/“father's”

(2) “you”/beneficiary's SN

(3) “You do”/“She does”/ “He does”

(4) “you”/“she”/“he”

(5) “your”/“her”/“his”

MAR026 Disallowed Spouse – Claimant has Re-married

 (1)  not qualify for benefits as a divorced  (2)  because  (3)  remarried and that marriage has not ended.

Fill-ins:

(1) “You do”/beneficiary's SN plus “does”

(2) “wife”/“husband”

(3) “you”/“she”/“he”

MHPC02 Caption

Information About  (1)  Health Plan Premiums

Fill-in:

(1) BGN plus BLN possessive/“Your”

MHP015 Award, Claimant Already Enrolled in Medicare Part C or D on another Account

Each month, we will continue to deduct  (1)  for  (2)  health plan premiums.

Fill-ins:

(1) Show the SUM of DAH-AMOUNT associated with DAH-ITEM 445 plus DAH-AMOUNT associated with DAH-ITEM 455 in the format $$$$$.CC

(2) BGN plus BLN (possessive)/ “your”

MHP043 Deduction for Medicare Part D

Each month, we will continue to deduct  (1)  for  (2)  Medicare prescription drug plan costs.

Fill-ins:

(1) PART D premium amount

(2) beneficiary's given name and last name, possessive/“your”

MHP044 Deduction for Medicare Part C and Part D

Each month, we will continue to deduct  (1)  for  (2)  health plan premiums and  (3)  for  (4)  Medicare prescription drug plan costs.

Fill-ins:

(1) PART C premium amount

(2) beneficiary's given name and last name, possessive/“your”

(3) PART D premium amount

(4) “her”/“his”/“your”

MHP053 Information about the Medicare Prescription Drug Plan (Part D)

Now that  (1)   (2)  eligible for Medicare,  (3)  can enroll in a Medicare prescription drug plan (Part D).

To learn more about the Medicare prescription drug plans and when  (4)  can enroll, visit  (5)  or call 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048). Medicare also can tell  (6)  about agencies in  (7)  area that can help  (8)  choose  (9)  prescription drug coverage.

If  (10)  limited income and resources, we encourage  (11)  to apply for the extra help that is available to assist with Medicare prescription drug costs. The extra help can pay the monthly premiums, annual deductibles and prescription co-payments. To learn more or apply, please visit  (12)  , call 1-800-772-1213 (TTY 1-800-325-0778) or visit the nearest Social Security office.

Fill-ins:

(1) Ms. plus BLN/Mr. plus BLN/BGN/BGN plus BLN/“you”

(2) “are”/“is”

(3) “she”/“he”/“you”

(4) “she”/“he”/“you”

(5) “http://www.medicare.gov

(6) “her”/ “him”/ “you”

(7) “her”/“his”/ “your”

(8) “her”/“him”/ “you”

(9) “her”/”his”/”your”

(10) “she has”/“he has”/ “you have”

(11) “her”/“him”/ “you”

(12) “www.socialsecurity.gov

MIS001 Abatement, Improper Applicant

We cannot process the application you filed for Social Security benefits on behalf of  (1)  because you are not the proper person to apply for benefits on  (2)  behalf.

Fill-ins:

(1) FN

(2) SN

MISR02 Misinformation Found, Earlier Filing Date

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

 (6)  did not file for benefits before  (7)  because we misinformed  (8)  about  (9)  eligibility for these benefits, and

 (10)  did not get benefits  (11)  could have.

We looked at the facts and found that we did misinform  (12)  . Therefore,  (13)  correct filing date is  (14)  . The beginning date for  (15)  benefits is based on this date.  (16) 

Fill-ins:

(1) “for” plus claimant's FN, otherwise NULL

(2) DOF in format “April 26, 1993”

(3) “you/the person who acted for you/the person who acted for, plus claimant's FN”

(4) Date in format “April 26, 1993” *

(5) Claimant's FN or “you”

(6) same as fill-in 3

(7) DOF in format “April 26, 1993”

(8) “you”/“her”/“him”

(9) FN possessive in format “Jack Jones” or last name possessive in format “Mr. Jones” or given name possessive in format “Jack's” or “your”

(10) “you”/“she”/“he”

(11) “you”/ “she”/ “he”

(12) same as fill-in 3

(13) same as fill-in 9

(14) Date of deemed filing in format “April 26, 1993” *

(15) “your”/“her”/“his”

(16) If fill-in 14 does not equal fill-in 4, then, “This is the earliest date, after we gave misinformation, that all requirements for these benefits were met.” Otherwise, NULL

(*) indicates that the fill-in is manual

MISR03 Misinformation Alleged, Earlier Filing Date Possible

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

 (6)  did not file for benefits before  (7)  because we misinformed  (8)  about  (9)  eligibility for these benefits, and

 (10)  did not get benefits  (11)  could have.

Fill-ins:

(1) “for” plus claimant's FN, otherwise NULL

(2) DOF in format “April 26, 1993”

(3) “you/the person who acted for you/the person who acted for, plus claimant's full name”

(4) Date of alleged misinformation in format “April 26, 1993” *

(5) Claimant's FN or “you”

(6) same as fill-in 3

(7) DOF in format “April 26, 1993”

(8) “you”/“her”/“him”

(9) FN possessive in format “Jack Jones'” or given name possessive in format “Jack's” or “Mr. Jones'” or “your”

(10) “you”/“she”/“he”

(11) “you”/ “she”/ “he”

(*) indicates that the fill-in is manual

MISR04 Misinformation Alleged Prior to January 1, 1983

You filed an application for benefits  (1)  on  (2)  . We can give  (3)  an earlier filing date if:

 (4)  did not file for these benefits before  (5)  because we misinformed  (6)  about  (7)  eligibility for these benefits, and

 (8)  did not get benefits  (9)  could have.

You said  (10)  did not file earlier because we gave misinformation on  (11)  . The law allows us to give  (12)  an earlier filing date if we misinformed  (13)  on or after January 1, 1983. Since you said we gave the misinformation before January 1, 1983, we are sorry but we cannot give  (14)  an earlier filing date.

Fill-ins:

(1) “for plus claimant's FN” or NULL

(2) DOF in format “April 26, 1993”

(3) Claimant's FN or “you”

(4) “you/the person who acted for you/the person who acted for, plus claimant's FN”

(5) DOF in format “April 26, 1993” *

(6) “you”/ “her”/ “him”

(7) Claimant's FN or “your”

(8) “you”/ “she”/ “he”

(9) “you”/ “she”/ “he”

(10) same as fill-in 4

(11) Date of alleged misinformation in format “April 26, 1993” *

(12) Claimant's FN or “you”

(13) “you”/ “her”/ “him”

(14) “you”/”her”/”him”

(*) indicates that the fill-in is manual

MISR05 Will Notify When Decision Made

We are looking into this and will let you know what we decide.

MISR06 Misinformation Alleged; Prior Filing Date Denied

We looked at the facts and found that we did not misinform  (1)  about  (2)  eligibility for these benefits. Therefore, we are sorry but  (3)  cannot get an earlier filing date.

Fill-ins:

(1) “you/the person who acted for you/the person who acted for, plus claimant's FN”

(2) Claimant's FN or “your”

(3) Claimant's FN possessive in format “Jack Jones” or “Mr. Jones” or “Jack's” or “you”

MISR07 To Applicant (Not Claimant) When Claimant Dies in or Before First MOE or During DIB Waiting Period

We are writing to tell you that we are not processing the application for Social Security benefits for  (1)  . This is because  (2)  could not have been entitled to benefits for any month before  (3)  death on  (4)  .

Fill-ins:

(1) FN

(2) “she/he”

(3) “her”/“his”

(4) month and year *

(*) indicates that the fill-in is manual

MOE001 Conditional Month of Entitlement

When  (1)  applied for benefits, you asked that they start in the earliest possible month based on your work. We will need to know how much  (2)  will actually earn in  (3)  before we can decide if  (4)  is the earliest possible month.

Fill-ins:

(1) Ms. plus BLN/ Mr. plus BLN/you

(2) “she”/ “he”/“you”

(3) Year of entitlement in the format YYYY

(4) Year of entitlement in the format YYYY

MOE002 Conditional MOE (Used Only with MOE001)

For this reason, we will contact you after you report  (1)  earnings for the year. We will let you know if  (2)  first month of entitlement to benefits will be changed.

Fill-ins:

(1) “your”/“her”/“his”

(2) “your”/“her”/“his”

MPDC19 Medicare Part D - Caption

Medicare Prescription Drug Plan Enrollment

MPDC31 IRMAA D - Caption

Information About The Prescription Drug Coverage Income Related Monthly Adjustment Amount

MPD348 IRMAA D Deducted from CMA

We deducted  (1)  for  (2)  prescription drug coverage income-related monthly adjustment amount from the check  (3)  will receive for  (4)  on or about  (5)  .

(1) Money amount

(2) BGN plus BLN, possessive/”your”

(3) “she”/“he”/“you”

(4) COM in format July 2013

(5) date in format January 3, 2013

MPD349 IRMAA D Deducted from MBP

The monthly deduction for  (1)  prescription drug coverage income-related monthly adjustment amount is  (2)  .

(1) BGN plus BLN, possessive/'your”

(2) Money amount

MSVC01 Military Service - Caption

Information About Military Service

MSV001 Military Service Not Usable, Other Federal Benefit

When we made our decision about  (1)  claim, we did not use  (2)  active military service for  (3)   (4)   (5)  . This is because another federal benefit is paid based on the same period of service. We cannot use active military service if another federal agency has used it to pay  (6)  a benefit.

Fill-ins:

(1) “your”/SN possessive/FN possessive

(2) “your”/NH SN possessive

(3) month and year

(4) “through”/null

(5) month and year/null

(6) “your”/NH SN

MSVR02 Military Service Not Usable, Less than 90 Days Service

When we made our decision about  (1)  claim we did not use  (2)  active military service for  (3)  . This is because  (4)  did not have at least 90 days of active service.

Fill-ins:

(1) “your”/SN possessive

(2) “your”/NH's SN possessive

(3) month/year through month/year *

(4) “you”/“she”/“he”

(*) indicates that the fill-in is manual

MSV005 Military Service Credits Before 1957 (Used Only with MSV004 or MSV010)

Please let us know if any other federal agency [except the Veteran's Administration] pays  (1)  a benefit based on this military service. Any other federal benefit  (2)   (3)  could affect the amount of  (4)  Social Security benefit.

Fill-ins:

(1) “you”/FN

(2) “you”/“she”/“he”

(3) “receive”/“receives”

(4) “your”/“her”/“his”

MSVR06 Military Service Unproven (Part or All)

We are checking to see if  (1)  active military service for  (2)  can be used in figuring the amount of  (3)  Social Security benefits. We will get in touch with you once we know if we can use this period of military service.

Fill-ins:

(1) “your”/NH's FN

(2) month/year; month/year and month/year; month/year through month/year *

(3) “your”/beneficiary's SN possessive

(*) indicates that the fill-in is manual

MSVR07 Military Service Not Used Due to Type of Discharge

When we made our decision about  (1)  claim, we did not use  (2)  active military service for  (3)  . We cannot use this service because of the type of discharge  (4)   (5)  .

Fill-ins:

(1) “your”/SN possessive/FN possessive

(2) “your”/NH's FN possessive

(3) month/year; month/year and month/year; month/year through month/year *

(4) “you”/NH's FN

(5) “have”/“has”

(*) indicates that the fill-in is manual

MSV010 Military Service Used

In addition to  (1)  earnings, we used  (2)  active military service to figure the amount of  (3)  Social Security benefits.

Fill-ins:

(1) “your”/NH FN possessive

(2) “your”/“her”/“his”

(3) “your”/SN possessive

ONS001 Onset Different From Alleged

The date we found  (1)  disabled is different from the date  (2)  gave us on the application.

Fill-in:

(1) FN/”you”

(2) “you”/“he”/ “she”

ONS002 Later Onset Established because Earnings Requirement Not Met until Later

 (1)  may have been disabled before this date  (2)  . However,  (3)  did not meet the disability earnings requirement until  (4)  . We explain this requirement in the enclosed pamphlet, called “How You Earn Credits.” (Pub #05-10072)

Fill-ins:

(1) null + FN/”She”/ “He”/ “You”

(2) onset date in the format “July 17, 2012”

(3) “she”/“he”/ “you”

(4) onset date in the format “July 17, 2012”

ONS003 Onset Date

We found that  (1)  became disabled under our rules on  (2)  .

Fill-ins:

(1) FN/“you”

(2) onset date in the format “July 17, 2012”

PAYC01 Caption

What We Will Pay And When

PAYC02 Caption

 (1)  Payment of $  (2) 

Fill-ins:

(1) “Your”/SN possessive

(2) Amount of payment

PAYC03 Caption

 (1)  Regular Monthly Payment

Fill-in:

(1) “Your”/SN possessive

PAYC04 Caption

 (1)  Payment of $  (2) 

Fill-ins:

(1) “Your”/SN possessive

(2) Amount of first payment

PAYC12 Caption

Why We Cannot Pay Current Benefits

PAYC15 Caption

Why We Cannot Pay Past Benefits

PAYR01 Partial Award

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

Fill-ins:

(1) “your”/Beneficiary's FN possessive

(2) dictated text *

(3) “you”/“her”/“him”

(4) “your”/“her”/“his”

(5) dictated text *

(6) “your”/“her”/“his”

(7) “you”/“her”/“him”

(8) “you”/“her”/“him”

(9) “your”/“her”/“his”

(*) indicates that the fill-in is manual

PAY002 PMA or CMA Different From Ongoing Amount

You will receive $  (1)  around  (2)  .

Fill-ins:

(1) Amount of first payment

(2) Month, day and year of expected receipt

PAY003 Payment Months (Concluding Sentence for PAY002)

This is the  (1)  money  (2)   (3)  due for  (4)   (5)   (6)  .

Fill-ins:

(1) null

(2) “you”/SN/FN/First Name

(3) “are”/“is”

(4) month and year

(5) “and”/“through”/null

(6) month and year/null

PAY004 Current or Deferred Benefits Due

You will receive $  (1)  for  (2)  around  (3)  .

Fill-ins:

(1) Payment amount

(2) Month and year payment is due

(3) Month, day and year of expected receipt

PAY006 Medical Insurance Premium Deduction

The above amounts may change because of medical insurance premium deductions.

PAY009 Ongoing Benefit Amount

 (1)  After that you will receive $  (2)   (3)   (4)   (5)  .

Fill-ins:

(1) null/”You will receive”

[1a] for [1b].

[1a] Money fill-in

[1b] Date fill-in the format “September 1995”

(2) Money fill-in

(3) “on or about the”/“for”/“through”

(4) “third”/ “second Wednesday”/ “third Wednesday”/ “fourth Wednesday”/Date in the format “July 1994”

(5) “of each month”/null

PAY012 Payment Through Direct Deposit

 (1)  and any future payments will go to the financial institution you selected. Please let us know if you change your mailing address, so we can send you letters directly.

Fill-in:

(1) “These”/“This”

PAY013 Monthly Credited Amount Less than One Dollar

 (1)  monthly benefits are less than a dollar. So, we will not pay you a check each month. We will hold the monthly benefits  (2)  due and pay you this money at the end of the year.

Fill-ins:

(1) “Your”/SN possessive/FN possessive/First Name possessive

(2) “you are”/“she is”/“he is”

PAY018 Summary Sheet Included

Later in this letter, we will show you how we figured  (1)   (2)  .

Fill-ins:

(1) null

(2) “this amount”/“these amounts”

PAY019 Summary Sheet - Introduction

Here is how we figured  (1)   (2)   (3)  :

Fill-ins:

(1) “your”/FN possessive

(2) “first payment”

(3) null

PAY020 Summary Sheet – Benefits Due

Benefits due for  (1)  . . . . . . . . . . . . . .  (2) 

Fill-ins:

(1) month and year

(2) null/“,”

PAY022 Summary Sheet – Subtraction Explanation

 (1)  we subtracted because  (2) 

Fill-ins;

(1) “Amount”/“Amounts”

(2) “of:”/“of”

PAY023 Summary Sheet - Introduction

Here is how we figured  (1)   (2)  effective  (3)  :

Fill-ins:

(1) FN possessive/“your”

(2) “regular monthly payment”

(3) Month and year

PAY024 Summary Sheet – Monthly Benefit Amount

 (1)  entitled to a monthly benefit of  (2)  . . . . . . .  (3) 

Fill-ins:

(1) “you are”/“she is”/“he is”

(2) null/variable length ellipsis

(3) MBA amount

PAY025 Summary Sheet – Monthly Payment Amount

This equals the amount of  (1)   (2)   (3)   (4) 

Fill-ins:

(1) SN possessive/“your”

(2) “first payment”

(3) variable length ellipsis

(4) Money amount

PAY026 Summary Sheet - Introduction

Here is how we figured  (1)   (2)  benefits:

Fill-ins:

(1) FN possessive/“your”

(2) “current”/“past”

PAYC27 Caption

How  (1)  Benefits Can Be Paid

Fill-in:

(1) Beneficiary's name (possessive)/ Your

PAY027 Summary Sheet – Subtraction Explanation

 (1)  we must subtract because  (2)  .

Fill-ins:

(1) “Amount”/“Amounts”

(2) “of”/“of:”

PAY028 Summary Sheet – Conditional Award Total

This equals . . . . . . . . . . . . . . .$00.00

PAY030 Combined Check

 (1)  benefit is $  (2)  on  (3)  earnings record and $  (4)  as a  (5)  .

Fill-ins:

(1) “your”/ “her”/ “his”

(2) Money fill-in

(3) “your”/ “her”/ “his”

(4) Money fill-in

(5) Type of benefit

PAY032 Auxiliary/Survivor Awarded after Primary

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

Fill-ins:

(1) “your”/ “her”/ “his”

(2) Money fill-in

(3) Type of benefit

(4) Money fill-in

(5) “your”/ “her”/ “his”

PAY033 Technical Entitlement – PMA Only Due in Addition to Regular Payment

 (1)  will also receive a payment of $  (2)  for  (3)  . This is the only money  (4)  due on claim number  (5)  .

Fill-ins:

(1) “you”/ “she”/ “he”

(2) Money fill-in

(3) Date fill-in

(4) “you are”/ “she is”/ “he is”

(5) DE other account SSN

PAY041 Summary Sheet – SMI Arrearage

Additional amount we subtracted for medical insurance premium due one month in advance  (1)  .

Fill-in:

(1) Premium amount

PAY042 Summary Sheet – Benefits Due

Benefits due for  (1)  . . . .  (2)  . . . .  (3) 

Fill-ins:

(1) Month and year

(2) null or variable length ellipsis

(3) Amount

PAY043 Payment Months (Concluding Sentence for PAY002, Two Periods of Payment)

This is the  (1)  money  (2)  due for  (3)   (4)   (5)  and  (6)   (7)   (8)  .

Fill-ins:

(1) null

(2) “you are”/ “she is”/ “he is”

(3) Month and year

(4) “and”/“through”/null

(5) Month and year/null

(6) Month and year

(7) “and”/“through”/null

(8) Month and year/null

PAY044 Payment Months (Concluding Sentence for PAY002, Three Periods of Payment)

This is the  (1)  money  (2)  due for  (3)   (4)   (5)  ,  (6)   (7)   (8)  and  (9)   (10)   (11)  .

Fill-ins:

(1) null

(2) “you are”/“she is”/“he is”

(3) Month and year

(4) “and”/“through”/null

(5) Month and year/null

(6) Month and year

(7) “and”/“through”/null

(8) Month and year/null

(9) Month and year

(10) “and”/“through”/null

(11) Month and year/null

PAY045 Payment Months (Concluding Sentence for PAY002, Four Periods of Payment)

This is the  (1)  money  (2)  due for  (3)   (4)   (5)  ,  (6)   (7)   (8)  ,  (9)   (10)   (11)  and  (12)   (13)   (14)  .

Fill-ins:

(1) null

(2) “you are”/“she is”/“he is”

(3) Month and year

(4) “and”/“through”/null

(5) Month and year/null

(6) Month and year

(7) “and”/“through”/null

(8) Month and year/null

(9) Month and year

(10) “and”/“through”/null

(11) Month and year/null

(12) Month and year

(13) “and”/“through”/null

(14) Month and year/null

PAY046 Summary Sheet – Work Deductions (Use with PAY022)

 (1)  work  (2)   (3) 

Fill-ins:

(1) NH FN possessive/“Your”

(2) null/variable length ellipsis

(3) Amount

PAY047 Summary Sheet – Maritime Tax Subtraction (Use with PAY022)

unpaid Social Security taxes due for  (1)  maritime taxes. . . .  (2) 

Fill-ins:

(1) FN possessive/“your”

(2) Amount

PAY048 Summary Sheet – SMI Premium Subtraction (Use with PAY022)

premiums for medical insurance . . . . . . . . . .  (1) 

Fill-in:

(1) Amount of premiums

PAY049 Summary Sheet - Subtotal

This equals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  (1) 

Fill-in:

(1) Amount

PAY050 Summary Sheet - Rounding

rounding [we must round down to a whole dollar] . . . . .  (1) 

Fill-in:

(1) Rounding amount

PAY051 Summary Sheet – Attorney Fee Withholding (Use with PAY022)

money to pay  (1)  lawyer . . . . . . . . . .  (2)  . . . . . . . .  (3) 

Fill-ins:

(1) FN possessive/“your”

(2) Variable length ellipsis/null

(3) Attorney fee withholding amount

PAY052 Summary Sheet – Alien Tax Withholding (Use with PAY022)

U.S. Federal taxes due on  (1)  Social Security  (2)   (3) 

Fill-in:

(1) FN possessive/“your”

(2) null/variable length ellipsis

(3) Amount of tax withheld

PAY053 Summary Sheet – Total Subtractions (Use with PAY022)

Total subtractions . . . . . . . . . . . . . . . . . .  (1) 

Fill-in:

(1) Amount

PAY054 Summary Sheet – Alien Non-payment (Use with PAY022)

 (1)  residence outside of the U.S . . . . . . . . .  (2) 

Fill-ins:

(1) FN possessive/“your”

(2) Amount

PAY055 Summary Sheet – Prisoner Suspension (Use with PAY027)

 (1)  conviction of a felony . . . . . . . . . . . .  (2) 

Fill-ins:

(1) FN possessive/“your”

(2) Amount withheld

PAY056 Summary Sheet – Work Deduction (Use with PAY027)

 (1)  work and earnings over the limit . . . . . . .  (2) 

Fill-ins:

(1) FN possessive/“your”

(2) Amount deducted

PAY057 Summary Sheet – Medical Insurance (Use with PAY027)

premiums for medical insurance . . . . . . . . . .  (1) 

Fill-in:

(1) Premium amount withheld

PAY058 Summary Sheet (Use with PAY020)

 (1)   (2)   (3) 

Fill-ins:

(1) “and”/“through”

(2) Month and year

(3) “,”/null

PAY059 Summary Sheet (Use with PAY020)

including any cost of living increase  (1)   (2) 

Fill-ins:

(1) “and”/null

(2) “,”/null

PAY060 Summary Sheet (Use with PAY020)

considering work and earnings through  (1) 

Fill-in:

(1) Year

PAY061 Summary Sheet (Use with PAY042)

 (1)   (2)   (3)   (4) 

Fill-ins:

(1) “and”/“through”

(2) Month and year

(3) null/variable length ellipsis

(4) Amount/null

PAY062 Summary Sheet (Use with PAY042)

with premiums for medical insurance deducted $  (1) 

Fill-in:

(1) Amount

PAY063 Summary Sheet

less monthly rounding of benefits $  (1) 

Fill-in:

(1) Amount

PAY064 Summary Sheet

premiums for medical insurance through  (1)   (2)   (3) 

Fill-ins:

(1) Month and year (COM)

(2) null/variable length ellipsis

(3) Amount

PAY065 Summary Sheet

additional premium due one month in advance . . . . $  (1) 

Fill-in:

(1) Amount

PAY066 Summary Sheet

government pension offset . . . . . . . . . . . . . $  (1) 

Fill-in:

(1) Amount

PAY067 Payment Prior to Completion of Claim/PMA Exists

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

Fill-ins:

(1) CPA in format $$,$$$.¢¢

(2) “your”/FN (Possessive)

PAY068 Payment Prior to Completion of Claim/Equal to PMA

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-ins:

(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-in is EFD minus one month in format January 1993.

(2) “your”/FN (Possessive)

PAY069 Summary Sheet

amount paid before work was finished on claim . . . . . . $  (1) 

Fill-in:

(1) CPA in format $$,$$$.¢¢

PAY072 Regular Monthly Payment When DAA/Installment Present

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

Fill-ins:

(1) “your”/“her”/“his”

(2) Money amount in format $$$.¢¢

(3) Month/year

PAY073 DAA Past Due Benefits and Installment

 (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-ins:

(1) “you are”/“she is”/“he is”

(2) Amount of past due benefit payable

(3) “you”/“she”/“he”

(4) “you”/“her”/“him”

(5) Amount of installment payment

(6) “your”/“her”/“his”

PAY074 Voluntary Tax Amount Withheld

voluntary withholding for Federal taxes.....................$  (1) 

Fill-in:

(1) Amount withheld for voluntary Federal tax withholding

PAY088 Payment Cycling

 (1)  next payment of $  (2)  , which is for  (3)  , will be received on or about the  (4)  of  (5)  .

Fill-ins:

(1) “Your”/beneficiary's FN possessive

(2) MBP in the format “$$$$$.¢¢”

(3) COM in the format “June 1998”

(4) third/second Wednesday/third Wednesday/fourth Wednesday

(5) COM + 1, in the format “June 1998”

PAY090 Summary Sheet (DE) Amount of Benefit on Other SSN

 (1)  also entitled to a monthly benefit of.........  (2)  .........  (3) 

Fill-ins:

(1) “you are”/“she is”/ “he is”

(2) Variable length ellipsis

(3) Money Fill-in

PAY161 LAF is C but the CMA is $0.00

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

Fill-in:

(1) “her”/“his”/“your”

PMT001 Payment Cycling – How Cycle is Established

The day of the month you receive  (1)  payments depends on  (2)  date of birth.

Fill-in:

(1) “your”/null plus FN possessive

(2) “your”/“his”/“her”

PMT002 Payment Cycling – Payment Date Change

Because  (1)  now entitled to benefits on a different Social Security record, the day you will receive  (2)  payment has changed.

Fill-ins:

(1) “you are”/Beneficiary's FN plus “is”/beneficiary's First Name plus “is”

(2) “your”/“her”/“his”

PRI011 DIB — Beneficiary Imprisoned Before 2/95

We may be able to pay  (1)  up to February 1995 if  (2)  in a rehabilitation program while  (3)  imprisoned. Two things must be true about the program:

It must be approved for  (4)  by a court, and

It must be designed to make it possible for  (5)  to work after  (6)  release.

Fill-ins:

(1) “you”/Beneficiary's FN

(2) “you were”/“she was”/“he was”

(3) “you were”/“she was”/“he was”

(4) “you”/“her”/“him”

(5) “you”/“her”/“him”

(6) “your”/“her”/“his”

PRI014 Beneficiary Imprisoned 2/95 through 3/31/2000

We cannot pay  (1)  because  (2)  imprisoned for the conviction of a crime that can carry a sentence of more than one year. We cannot pay  (3)  even if  (4)  actual sentence is shorter.

Fill-ins:

(1) “you”/Beneficiary's FN

(2) “you are”/“she is”/ “he is”

(3) “you”/“her”/“him”

(4) “your”/“her”/”his”

PRI015 Beneficiary Imprisoned Before 2/95

We cannot pay  (1)  because  (2)  imprisoned before February 1995 for the conviction of a crime considered to be a felony. Beginning February 1995, the law changed. Now, we cannot pay Social Security benefits if  (3)  imprisoned for conviction of a crime that can carry a sentence of more than one year. We cannot pay  (4)  benefits even if  (5)  actual sentence is shorter.

Fill-ins:

(1) “you”/Beneficiary's FN

(2) “you were”/“she was”/“he was”

(3) “you are”/“she is”/ “he is”

(4) “you”/“her”/“him”

(5) “your”/“her”/“his”

PRI016 Number Holder Imprisoned – Entitled Auxiliaries Can be Paid

Even though we cannot pay  (1)  , we can pay other members of  (2)  family if they are entitled on  (3)  record.

Fill-ins:

(1) “you”/Beneficiary's FN

(2) “your”/“her”/“his”

(3) “your”/“her”/“his”

PRI017 Benefits Payable after Release from Prison

We may be able to pay  (1)  when  (2)  released. Please get in touch with us after  (3)  released. Then we will review your case to see if we can pay  (4)  .

Fill-ins:

(1) “you”/Beneficiary's FN

(2) “you are”/“she is”/“he is”

(3) “you are”/“she is”/“he is”

(4) “you”/“her”/“him”

PRI021 Suspending Benefits to a Sexually Dangerous Person

We cannot pay  (1)  because:

 (2)  convicted of a crime and confined in a jail or prison;

The crime included sexual activity, and

when  (3)  completed  (4)  sentence,  (5)  immediately sent by court order to an institution at public expense.

The court decided  (6)  a sexually dangerous person.

Fill-ins:

(1) Ms plus BLN/Mr plus BLN/BGN/BGN plus BLN/”you”

(2) “she was”/“he was”/“you were”

(3) “she”/“he”/“you”

(4) “her”/“his”/“your”

(5) “she was”/“he was”/“you were”

(6) “she was”/“he was”/“you were”

PRI030 Beneficiary Suspended 4/2000 or Later Due to a Non-Felony Conviction

We cannot pay  (1)  because  (2)  imprisoned for the conviction of a crime.

Fill-ins:

(1) “you”/name

(2) ““she is”/“he is”/“you are””

PRI049 Explains Provisions of PL 108-203 (Fugitive Felon Suspensions)

Beginning January 2005, the law prohibits us from paying Social Security benefits to individuals who have an outstanding arrest warrant for a crime which is a felony (or, in jurisdictions that do not define crimes as felonies, a crime that is punishable by death or imprisonment for a term exceeding 1 year), or who have violated a condition of probation or parole under Federal or State law. We have information that  (1)   (2)  into one of these categories.

Fill-ins:

(1) BGN plus BLN/”you”

(2) “falls”/ “fall”

RDE001 Withholding – Maritime Service

We have withheld from  (1)  first check unpaid Social Security taxes of  (2)  for maritime services.

Fill-ins:

(1) “your”/“her”/“his”

(2) Amount in format “$99,999.99”

RDE002 Reduced Benefits – Other Entitlement

We reduced  (1)  monthly benefit amount beginning  (2)  because we started paying another person on this record.

Fill-ins:

(1) FN possessive/“your”

(2) Date in format “August 1991”

REC005 English Translation for Spanish Cover Letter – Affirmation of Denial on Reconsideration – Domestic/Foreign Address

The enclosed English version of the “Determination of Reconsideration” explains why your claim cannot be approved. If you need help with the translation, ask someone who understands both English and Spanish to help you. Or contact any Social Security office.

REC006 English Translation for Spanish Cover Letter – Affirmation of Denial on Reconsideration – Mexico Address

The enclosed English version of the “Determination of Reconsideration” explains why your claim cannot be approved. If you need help with the translation, ask someone familiar with both languages to help you, or contact any Social Security office or the nearest U.S. Embassy or Consulate.

REFC01 Caption

If You Have Any Questions

REF001 Referral – Domestic Address

We invite you to visit our website at www.ssa.gov on the Internet to find general information about Social Security. However, if you have any specific  (1)  questions, you can call us at 1-800-772-1213. We can answer most questions over the phone. If you are deaf or hard of hearing, you may call our TTY number, 1-800-325-0778. You can also write or visit any Social Security office. The office that serves you area is located at:

 (2) 

If you do call or visit an office, please have this letter with you. It will help us answer your questions.

Fill-ins:

(1) null

(2) Field office address

REF002 Referral – Foreign Address

We invite you to visit our website at www.ssa.gov on the Internet to find general information about Social Security. However, if you have any specific  (1)  questions, you can call us at 1-800-772-1213. We can answer most questions over the phone. If you are deaf or hard of hearing, you may call our TTY number, 1-800-325-0778. You can also write or visit any Social Security office. The office that serves you area is located at:

 (2) 

If you do call or visit an office, please have this letter with you. It will help us answer your questions.

Fill-ins:

(1) null

(2) “any Social Security office”/“the Veterans Affairs Regional Office, Social Security Division, 1131 Roxas Boulevard, Manila”/“any Social Security office or the nearest United States Embassy or consulate”/“any Social Security office or the nearest United States Embassy or consulate. Or, if you live in the Philippines, you may contact the Veterans Administration Regional Office, Social Security Division, 1131 Roxas Boulevard, Manila/the nearest United States Embassy or consulate”

REF003 Referral – Domestic Address

We invite you to visit our website at www.ssa.gov on the Internet to find general information about Social Security. If you have any specific questions, you may call us toll free at 1-800-772-1213, or call your local Social Security office at  (1)  .

We can answer most questions over the phone. If you are deaf or hard of hearing, you may call our TTY number, 1-800-325-0778. You can also write or visit any Social Security office. The office that serves you area is located at:

 (2) 

If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

Fill-ins:

Local field office telephone number in the format 1-XXX-XXX-XXXX

Field Office Address

REF008 Field Office Referral - Default

We invite you to visit our website at www.ssa.gov on the Internet to find general information about Social Security. If you have any specific  (1)  questions, call us toll-free at 1-800-772-1213. We can answer most questions over the phone. If you prefer to visit one of our offices, please check the local telephone directory for the office nearest you. Or call us and we can give you the office address. Please have this letter with you if you call or visit an office. It will help us answer your questions.

Fill-in:

(1) null

REF011 Referral (Award Notice Only) 10 Digit Title II Public Contact Number other than National Number) and LAF = E

If you have any questions about your Social Security benefits, call us toll free at 1-800-772-1213, or call the local Social Security office at  (1)  . We can answer most questions over the phone. You can also write or visit any Social Security office. The office that serves you area is located at:

 (2) 

If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

If you have any questions about railroad annuities or about your monthly check, please contact your local Railroad District office or the Railroad Retirement Board.

The address is:

U.S. Railroad Retirement Board

844 Rush Street

Chicago, Illinois 60611-2092

Fill-ins:

(1) Local DO telephone number on TRIDE in format 1-xxx-xxx-xxxx

(2) Street address, City, State and Zip Code corresponding to DOC

REF012 Referral (Award Notice Only) - Default

If you have any questions about your Social Security benefits, call us toll free at 1-800-772-1213. We can answer most questions over the phone. You can also write or visit any Social Security Administration office. If you prefer to visit one of our offices, call the 800 number and we can give you the local office address and telephone number.

If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

If you have any questions about railroad annuities or about your monthly check, please contact your local Railroad District office or the Railroad Retirement Board.

The address is:

U.S. Railroad Retirement Board

844 Rush Street

Chicago, Illinois 60611-2092

REF013 Referral Without Field Office Phone Number (Award Notice Only)

If you have any questions about your Social Security benefits, call us toll free at 1-800-772-1213. We can answer most questions over the phone. You can also write or visit any social Security office. The office that serves you area is located at:

 (1) 

If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

If you have any questions about railroad annuities or about your monthly check, please contact your local Railroad District office or the Railroad Retirement Board.

The address is:

U.S. Railroad Retirement Board

844 Rush Street

Chicago, Illinois 60611-2092

REF050 English Translation for Spanish Cover Letter – Awards – Domestic/Foreign Address

The attached sheet explains your right to question the decision on your claim. If you have any questions, contact any Social Security office. Most of your questions can be answered by telephone or mail. If you visit an office, please have this notice with you.

RELD01 Dictated Text

RELD02 Dictated Text

REL002 Disallowance – Divorced Claimant not Married 10 Years

 (1)  not qualify for benefits as a divorced  (2)  because  (3)  not married to  (4)  for at least 10 years in a row.

The facts we have do not show that this requirement is met.

Fill-ins:

(1) “You do”/“She does”/“He does”

(2) “wife”/“husband”/“widow”/“widower”

(3) “you were”/“she was”/“he was”

(4) NH FN

REL004 Disallowance – Child's Relationship Not Proven

 (1)  not qualify for benefits because the facts we have do not show that  (2)   (3)  child.

Fill-ins:

(1) “You do”/“She does”/“He does”

(2) “you are”/“she is”/ “he is”

(3) NH FN possessive

REL006 Disallowance – Adopted Child – Equitable Adoption Does not Apply

 (1)  not qualify for child's benefits on  (2)  Social Security record because the facts we have show that:

  •  (3)  not adopted by  (4)  , and

  •  (5)  not have the right to inherit from  (6)  as  (7)  child under the laws of  (8)  .

Fill-ins:

(1) “You do”/“She does”/ “He does”

(2) NH-name possessive

(3) “you were”/“she was”/“he was”

(4) “her”/“him”

(5) “You do”/“She does”/ “He does”

(6) “her”/“him”

(7) “her”/“his”

(8) State name

RELR07 Disallowance – Child not Adopted by Number Holder

 (1)  not qualify for benefits as an adopted child on  (2)  Social Security record because:

 (3)  not  (4)  natural child or stepchild, and

 (5)  not adopted by  (6)  through a court action in the United States.

Fill-ins:

(1) “You do”/“She does”/ “He does”

(2) NH-name possessive

(3) “you are”/“she is”/ “he is”

(4) ““her”/“his””

(5) “you were”/“she was”/“he was”

(6) NH SN

REL009 Disallowance – Adoption by Number Holder's Surviving Spouse not within Time Limit

 (1)  not qualify for benefits as  (2)  child because:

 (3)  did not begin the adoption proceedings before  (4)  died, and

 (5)  did not complete the proceedings within 2 years of  (6)  death.

Fill-ins:

(1) “You do”/ “She does”/ “He does”

(2) NH-Name possessive

(3) SN of NH

(4) “she”/“he”

(5) Surviving spouse name

(6) “her”/“his”

REL010 Surviving Divorced Mother/Father Does not have Proper Relationship to Child

To quality for  (1)  benefits,  (2)  must meet one of these requirements:

 (3)  the natural  (4)  of  (5)  child, or

 (6)  adopted  (7)  child while  (8)  married to  (9)  , or

 (10)  adopted  (11)  child while  (12)  married to  (13)  , or

 (14)  and  (15)  adopted a child while married.

The facts we have do not show that any of these requirements is met.

Fill-ins:

(1) “mother's”/“father's”

(2) “you”/“she”/“he”

(3) “you are”/“she is”/ “he is”

(4) “mother”/“father”

(5) NH FN possessive

(6) NH SN

(7) “your”/“her”/“his”

(8) ““she was”/ “he was”/ “you were””

(9) “her”/“him”

(10) “you”/“she”/“he”

(11) NH SN possessive

(12) “she was”/ “he was”/“you were”

(13) “her”/“him”

(14) “you”/“she”/ “he”

(15) NH SN

REL011 Stepparent Disallowance – Parent and Stepparent Divorced before Stepchild's First Possible Month of Entitlement

If  (1)  legally adopted  (2)  , contact us because  (3)  may qualify for benefits as an adopted child.

Fill-ins:

(1) NH full name

(2) “you”/beneficiary's full name

(3) “you”/“she”/“he”

REL012 Disallowance – Claimant is Stepchild – Requirement for Duration of Parents' Marriage not Met

 (1)  not qualify for child's benefits on  (2)  Social Security record because  (3)  and  (4)   (5)  were not married for at least  (6)  . Our records show that they were married on  (7)  and  (8)  on  (9)  .

Fill-ins:

(1) “You do”/“She does”/ “He does”

(2) NH-Name possessive

(3) Mr.plus NH-SURNAME/Ms. plus NH-SURNAME

(4) “mother”/“father”

(4) “9 months/“12 months before [6a] applied for benefits.”

[6a] “you”/“she”/ “he” Date NH married child's parent, in format, June 10, 1991 “(NH-SN) died”/“(8a) applied”

[8a] “you”/“she”/“he” NH's date of death or claimant application date, in format July 10, 1991

RELR13 Disallowance – Stepchild Claimant – Natural Parent and Stepparent Divorced before Application Filed

 (1)  not qualify for benefits on  (2)  Social Security record because  (3)  and  (4)   (5)  divorced before  (6)  .

Fill-ins:

(1) “You do”/“She does”/“He does”

(2) FN of NH possessive

(3) FN of NH

(4) “Your”/NOTICE-PIC-NAME

(5) “mother”/“father”

(6) “(NH surname) died”/“[6a] applied for benefits”

[6a] “you”/“she”/“he”

REL014 Disallowance – Stepchild, Grandchild or Step-grandchild

 (1)  not qualify for benefits because the facts we have do not show that  (2)   (3)  of  (4)  .

Fill-ins:

(1) “You do”/ “She does”/”He does” “

(2) “you are”/“she is”/ “he is”

(3) “the stepchild”/“the grandchild or step grandchild”

(4) NH-name

REL015 Disallowance – Parent not the Parent of the Number Holder

 (1)  not qualify for benefits because the facts we have do not show that  (2)   (3)   (4)  .

Fill-ins:

(1) “You do”/“She does”/ “He does”

(2) “you are”/“she is”/ “he is”

(3) NH-Name possessive

(4) “parent”/“stepparent”/“adoptive parent”

REL016 Disallowance – Adoptive Parent

 (1)  not qualify for parent's benefits on  (2)  Social Security record because  (3)  did not adopt  (4)  before  (5)  reached age 16. Our records show that  (6)  was born on  (7)  and that the adoption was final on  (8)  .

Fill-ins:

(1) “You do”/ “She does”/ “He does”

(2) NH-name possessive

(3) “you”/“she”/“he”

(4) “her”/“him”

(5) “she”/“he”

(6) “she”/“he”

(7) NH-DOB, in format June 6, 1969

(8) Date of adoption, in format April 5, 1989

REL017 Disallowance – Not a Parent

 (1)  not qualify for benefits as  (2)  parent because  (3)  did not marry  (4)   (5)  before  (6)  reached age 16. Our records show that  (7)  was born on  (8)  and that  (9)  married  (10)   (11)  on  (12)  .

Fill-ins:

(1) “You do”/“She does”/ “He does”

(2) NH-name possessive

(3) “you”/“she”/“he”

(4) “her”/“his”

(5) “mother”/“father”

(6) NH-name

(7) NH SN

(8) NH's DOB

(9) “you”/“she”/“he”

(10) “her”/“his”

(11) “mother”/“father”

(12) Marriage date in the format September 13, 1999

REL023 Disallowance – Claimant does not Meet Duration of Marriage Requirement or Alternative

 (1)  not qualify for benefits as  (2)   (3)  because:

 (4)  not married to  (5)  for at least  (6)   (7)  , or

 (8)  not the natural or adoptive parent of  (9)  child.

Fill-ins:

(1) “You do”/“She does”/ “He does”

(2) NH FN possessive

(3) “husband”/“wife”/“widower”/“widow”

(4) “you were”/“she was”/“he was”

(5) “her”/“him”

(6) “9 months before”/“one year just before applying for benefits”

(7) “he died”/“she died”/null

(8) “you are”/“she is”/“he is”

(9) “her”/“his”

REL024 Disallowance - 216H2a or 216H3 Child –Relationship not Established (REL024 Replaces REL005)

 (1)  not qualify for child's benefits because the facts we have do not show that  (2)   (3)  child.

To qualify as a child, one of the following must be true:

The child has the right to inherit the worker's personal property as a natural child. This is based on the inheritance laws of the state where the worker and his or her home when he or she died or when the child's claim was filed, or

The worker stated in writing that the child is his or her son or daughter, or

A court ordered the worker to contribute to the child's support because the child is his or her son or daughter, or

A court found that the worker is the child's father or mother, or

There are other facts which show that the worker is the child's father or mother. And the worker was living with the child or was contributing to the child's support when the worker died or when the child's application was filed.

The facts we have show that none of these are true about  (4)  relationship to  (5)  .

Fill-ins:

(1) You do/She does/He does

(2) “you are”/“she is”/“he is”

(3) NH name (possessive)

(4) your/Beneficiaries name, possessive

(5) NH name

REPC01 Attorney Representation - Caption

If You Want Help With Your Appeal

REP001 Attorney Representation

You can have a friend, lawyer or someone else help you. There are groups that can help you find a lawyer or give you free legal services if you qualify. There are also lawyers who do not charge unless you win your appeal. Your local Social Security office has a list of groups that can help you with your appeal.

If you get someone to help you, you should let us know. If you hire someone, we must approve the fee before he or she can collect it. And if you hire a lawyer, we will withhold up to 25 percent of any past due benefits to pay toward the fee.

RIN001 Benefit Increase – Beneficiary Terminated

We raised  (1)  monthly benefit amount beginning  (2)  because benefits to another entitled person stopped.

Fill-ins:

(1) SN possessive/“your”

(2) Month and year of increase, in format June 1991

RIN003 Benefit Increase – Due to Death

We raised  (1)  monthly benefit beginning  (2)  because of  (3)  death in  (4)  .

Fill-ins:

(1) SN possessive/“your”

(2) Month and year of increase in format “June 1991”

(3) Beneficiary's name possessive

(4) Date of death in format “June 1991”

RIN011 Increased Auxiliary Benefit because of Number Holder Increase

We changed  (1)  monthly benefit amount beginning  (2)   (3)  because we raised  (4)  benefit.

Fill-ins:

(1) “your”/“her”/“his”

(2) Earliest month of benefit increase, in format June 2008

(3) null/“and again in”

(4) Month YYYY/Month YYYY and Month YYYY/Month YYYY, Month YYYY and Month YYYY

(5) NH-name possessive

RIN016 COLA Increase(s) and Re-computation

We raised  (1)  monthly benefit amount beginning  (2)  because the cost of living increased. We also raised  (3)  monthly benefit in  (4)  to give  (5)  credit for  (6)   (7)  earnings. We use each year's earnings to raise benefits the following January.

Fill-ins:

(1) possessive in format “Mr. Jones'” or “your”

(2) Month YYYY/Month YYYY and again beginning Month YYYY/Month YYYY, Month YYYY and Month YYYY/Month YYYY, Month YYYY, Month YYYY and Month YYYY/ Month YYYY, Month YYYY, Month YYYY, Month YYYY and Month YYYY

(3) “your”/“her”/“his”

(4) Date in format “January 1992/January 1992 and January 1993/January 1992, January 1993 and January 1994”

(5) “you/“her”/“his”

(6) “your”/“her”/“his”

(7) Show year preceding year in fill-in (4) in format “1991/1991 and 1992/1991, 1992 and 1993”

RIN017 COLA Increase and Re-computation - Auxiliary

We changed  (1)  monthly benefit amount beginning  (2)  because the cost of living increased. We also raised  (3)  benefit beginning  (4)  .

Fill-ins:

(1) SN possessive in format “Mr. Jones” or “your”

(2) Month YYYY/Month YYYY and again beginning Month YYYY/Month YYYY, Month YYYY and Month YYYY/Month YYYY, Month YYYY, Month YYYY and Month YYYY/Month YYYY, Month YYYY, Month YYYY, Month YYYY and Month YYYY

(3) “your”/“her”/“his”

(4) Month YYYY/Month YYYY and Month YYYY/Month YYYY, Month YYYY and Month YYYY/Month YYYY, Month YYYY, Month YYYY and Month YYYY

RIN020 Benefit Increased – Credit for Work Months

We raised  (1)  monthly benefit starting  (2)  . We gave  (3)  credit for months when  (4)  :

  • At least full retirement age, and

  • Did not receive a retirement benefit because of  (5)  work and earnings

Fill-ins:

(1) FN possessive /“your”

(2) date of increase in the format “June 1998”

(3) “you”/”him”/'her”

(4) “you were”/”he was”/”she was”

(5) “your”/“his”/“her”

RIN021 Benefit Increase – Incorrectly Paid

We raised  (1)  monthly benefit beginning  (2)  to give credit for benefits which we did not pay at the full rate before  (3)  reached  (4)   (5)   (6)   (7)   (8)  .

Fill-ins:

(1) “your”/Ms. plus beneficiary's last name, possessive/Mr. plus beneficiary's last name, possessive

(2) date, in the format June 1998

(3) “you”/“she”/“he”

(4) age 62/full retirement age,

(5) full retirement age, in the format “65”/null

(6) “and”/null

(7) additional FRA months, in the format “2”/null

(8) months/null

RIN054 Number Holder's Benefit Increased by Two or More Re-computations, but not More than 4

We again raised  (1)  monthly benefit beginning  (2)  to give

credit for  (3)   (4)  earnings.

Fill-ins:

(1) “your”/“her”/“his”

(2) Month YYYY/Month YYYY and Month YYYY/Month YYYY, Month YYYY and Month YYYY

(3) “your”/“her”/“his”

(4) YYYY/YYYY and YYYY/YYYY, YYYY and YYYY

RIN055 Number Holder's Benefit Increased by One Re-computation

We raised  (1)  monthly benefit amount beginning  (2)  to give  (3)  credit for  (4)   (5)  earnings. We use each year's earnings to raise benefits the following January.

Fill-ins:

(1) “your”/“her”/“his”

(2) earliest PIA increase in the format “Month YYYY”

(3) “you”/“her”/“him”

(4) “your”/“her”/“his”

(5) YYY

RPY006 Award Notice to Beneficiary in S8

If you know someone who can be your payee, please call us at either of the telephone numbers shown at the end of this letter. We will consider this person for your payee. Also, call us within the next 30 days if you do not hear from us. You may be able to get some payments directly while we make our decision.

RPY057 Representative Payee Appointed

We have chosen you to be  (1)  representative payee. Therefore  (2)  , you will receive  (3)  checks and use the money for  (4)  needs.

Fill-ins:

(1) “her”/“his”

(2) null/“if [2a] due benefits in the future”

[2a] “she is”/“he is”

(3) “her”/“his”

(4) “her”/“his”

RRB001 Number Holder has at Least 120 Months of Railroad Service

The Railroad Retirement Board will make Social Security payments to you. This is because you, your spouse, or the person on whose Social Security record you filed worked for at least 10 years in the railroad industry.

RRB002 RRB Jurisdiction

The Railroad Board will write to let you know when you will get a check and how much it will be. If you are getting a Railroad Retirement annuity, they will also explain any reduction in your annuity because of your Social Security payments.

If you have not already applied for a Railroad Retirement annuity and wish to do so, you must apply at a Railroad Board office. They decide whether you can get an annuity.

The Railroad Retirement board will send you one check each month. This check will include your Social Security benefit and any Railroad Retirement annuity you are due.

RSD007 Medicare Disallowance - Residency

 (1)  cannot qualify for Medicare because  (2)  did not live in any of the 50 states, the District of Columbia, the Commonwealth of Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa or the Northern Mariana Islands at the time  (3)  applied for Medicare.

 (4)  may be able to buy Medicare coverage in the future. If  (5)  a citizen of the United States,  (6)  can buy Medicare as soon as  (7)  to this country.

If  (8)  not a citizen,  (9)  can buy Medicare only after  (10)  lived in the United States for five years in a row. These must be the five years right before  (11)  for Medicare. Also, as an alien  (12)  must be lawfully admitted for permanent residence.

Fill-ins:

(1) “You”/Ms. plus BLN/Mr. plus BLN/BGN/BGN plus BLN

(2) “you”/“she”/“he”

(3) “you”/“she”/“he”

(4) “you”/“she”/“he”

(5) “you are”/“she is”/“he is”

(6) “you”/“she”/“he”

(7) “you return/she returns/he” returns

(8) “you are”/“she is”/ “he is”

(9) “you”/“she”/“he”

(10) “you have”/“she has”/“he has”

(11) “you apply”/“she applies”/ “he applies”

(12) “you”/ “she”/ “he”

SEIC01 Caption

We Did Not Use Some Of  (1)  Earnings

Fill-in:

(1) SN possessive/“Your”

SEID01 Dictated Text

SEIR01 Income not SEI

We could not use  (1)  income for  (2)  as earnings from self-employment because  (3)  .

Fill-ins:

(1) “your”/Ms. or Mr. plus number holder's last name

*(2) year(s) in the format “YYYY” or “YYYY and YYYY” or “YYYY, YYYY and YYYY”

*(3)

A. Income from renting rooms and apartments is not self-employment income unless special services are given to the tenants

B. a farm owner's share of income usually is not self- employment income when a tenant works the farm

C. Income from renting real estate is not self-employment income unless it is received as part of a real estate dealer's ordinary work

D. Capital gains and losses are not considered self- employment income. Only gains and losses from disposing of inventory can be considered self-employment income

E. Income from the sale of livestock for dairy work or for breeding is not self-employment income

F. not all business deductions were taken. All deductions from income must be taken when a self-employment tax return is filed with the Internal Revenue Service

G. the income was not received from a trade or business. We only consider income received from a trade or business to be self-employment income

H. the income does not meet our requirements to be considered as self-employment income

(*) indicates that the fill-in is manual

SEIR02 SEI Determination Pending

We have not decided whether your income for  (1)  was self-employment income. We will let you know as soon as we make this decision. If we decide that it was self-employment income, we will also tell you if it will increase your benefit.

Fill-in:

(1) Year(s) *

(*) indicates that the fill-in is manual

SEIR03 SEI not Used – Tax Return not Filed Timely

We could not use  (1)  income from self- employment for  (2)  because a federal tax return to report it was not filed on time. To be considered on time, tax returns have to be filed within 3 years, 3 months, and 15 days from the end of the taxable year.

Fill-ins:

(1) SN possessive/“your”

(2) Year(s) *

(*) indicates that the fill-in is manual

SEIR04 SEI not Used – No Proof

We asked you for proof of  (1)  income from self-employment for  (2)  . We have not considered this income because  (3)   (4)  not given us the proof we asked for.

Fill-ins:

(1) SN possessive/“your” *

(2) Year(s)

(3) “you”/“she”/“he” *

(4) “have”/“has” *

(*) indicates that the fill-in is manual

SEIR05 SEI Amount Adjusted

 (1)  reported self-employment income of $  (2)  for  (3)  . We have reduced this to $  (4)  because  (5)  .

Fill-ins:

(1) SN

(2) Old dollar amount *

(3) Year *

(4) New dollar amount *

(5)

a. “income from renting the rooms and apartments is not self-employment income unless special services are given to the tenants” *

b. “a farm owner's share of income usually is not self-employment income when a tenant works the farm”

c. “income from renting real estate is not self-employment income unless it is received as part of a real estate dealer's ordinary work”

d. “capital gains and losses are not considered self-employment income. Only gains and losses from disposing of inventory can be considered self-employment income”

e. “income from the sale of livestock for dairy work or breeding is not self-employment income”

f. “not all business deductions were taken. All deductions from income must be taken when a self-employment tax return is filed with the Internal Revenue Service”

g. “the income was not received from a trade or business. We only consider income received from a trade or business to be self-employment income”

(*) indicates that the fill-in is manual

SEI006 SEI Adjustment Referred to IRS

We will send a copy of our decision about  (1)  self-employment earnings to the Internal Revenue Service. They will make any changes that are needed to the tax record.

Fill-in:

(1) “your”/name

SEIR07 SEI not Used – Under Limit

Net income from self-employment of less than $400 per year is not considered earnings for Social Security purposes. Since we reduced your self-employment income for  (1)  to less than $400, it does not count as Social Security earnings.

Fill-in:

(1) Year *

(*) indicates that the fill-in is manual

SSAH01 First and Second Line Headings

Social Security Administration

Retirement, Survivors and Disability Insurance

SSAH02 Third Line Heading

Notice of Award

SSAH03 Third Line Heading

Notice of Disapproved Claim

SSAH04 Third Line Heading

Claim Information

SSAH05 Third Line Heading

Important Information

SSAH28 Date

Date:

Claim Number:

SSAH30 Payment Name and Address

Addressee

SSAH40 Return Address

Northeastern Program Service Center
155-10 Jamaica Avenue
Jamaica, New York 11432-3898

SSAH41 Return Address

Mid-Atlantic Program Service Center
300 Spring Garden Street
Philadelphia, Pennsylvania 19123-2992

SSAH42 Return Address

Southeastern Program Service Center
1200 Rev. Abraham Woods, Jr. Blvd
Birmingham, Alabama 35285-0001

SSAH43 Return Address

Great Lakes Program Service Center
600 West Madison Street
Chicago, Illinois 60661-2474

SSAH44 Return Address

Western Program Service Center
P.O. Box 2000
Richmond, California 94802-1000

SSAH45 Return Address

Mid-America Program Service Center
601 East Twelfth Street
Kansas City, Missouri 64106-2859

SSAH46 Return Address

Office of Central Operations
1500 Woodlawn Drive
Baltimore, Maryland 21241-1500

SSAH47 Return Address

Office of Central Operations
P.O. Box 17769
Baltimore, Maryland 21235-7769 U.S.A.

Fill-ins for SSAH40 - SSAH47

(1) TELEPHONE CONTACT/CERTIFIED MAIL/null

(2) Actual telephone number in format ###-###-#### if number is available and if fill-in (1) = TELEPHONE CONTACT, otherwise null.

SSAS01 Signature

(Signature of Commissioner of Social Security)

First Name Last Name

Commissioner of Social Security

SSAS02 Signature

Social Security Administration

SSAS03 Signature

Social Security Administration

SSAS04 Signature

Social Security Administration

SSAS05 Signature

Social Security Administration

SSAS06 Signature

Social Security Administration

SSAS07 Signature

Social Security Administration

SSAS08 Signature

Social Security Administration

SSAS09 Signature

Social Security Administration

STU003 Student Disallowance – Not Attending Approved School

 (1)  not qualify for student's benefits because  (2)  not attending an elementary or secondary level high school which has been approved by a State or local government.

Fill-ins:

(1) “You do”/”She does”/”He does”

(2) “you are”/”she is”/”he is”/”you were”/”she was”/”he was”

STU005 Student Disallowance – Employer Involvement

 (1)  not qualify for student's benefits because  (2)  employer is paying  (3)  to go to school.

Fill-ins:

(1) “You do”/”She does”/”He does”

(2) “your”/”her”/”his”

(3) “you”/”her”/”him”

STUR06 Student Disallowance

 (1)  not qualify for student's benefits because  (2)  imprisoned for the conviction of a crime considered to be a felony.

Fill-ins:

(1) “You do”/”She does”/”He does”

(2) “you are”/”she is”/”he is”

STU007 Student Does not Meet Requirements for Full-time School Attendance

To qualify for student benefits:

 (1)  must be scheduled to attend school at least 20 hours a week, or

The school must consider  (2)  to be in full-time attendance, and

 (3)  course of study must last at least 13 weeks, and

 (4)  must be enrolled in a course that is not a correspondence course.

Fill-ins:

(1) “You”/full name

(2) “you”/”her”/“him”

(3) “your”/”her”/“his”

(4) “you”/”she”/ “he”

SUS001 Benefits Suspended Non-Citizen Outside of U.S. Over 6 Months

We cannot pay  (1)  benefits  (2)   (3)  because  (4)  not a citizen of the United States and  (5)  been living outside the country for more than 6 months. Please read the enclosed pamphlet, “Your Social Security Checks - While You are Outside the United States,” for more information about this.

Fill-ins:

(1) SN/“you”

(2) null/“beginning”

(3) Month and year/null

(4) “you are”/ “she is”/ “he is”

(5) “you have”/“she has”/”he has”

SUS003 Benefits Suspended – U.S. Citizen Outside U.S.

We cannot pay you the benefits  (1)   (2)  due while you live in  (3)  . If  (4)   (5)  to another country, we may be able to begin payments. Please contact us if this happens.

Fill-ins:

(1) SN/“you”

(2) “are”/“is”

(3) Name of country of residence

(4) “you”/“she”/ “he”

(5) “move”/“moves”

SUS004 Benefits Suspended – Non U.S. Citizen Outside U.S.

 (1)   (2)  not due benefits while  (3)   (4)  in  (5)  . If  (6)   (7)  to another country, we may be able to begin payments. Please contact us if this happens.

Fill-ins:

(1) SN/“You”

(2) “are”/“is”

(3) “you”/“she”/ “he”

(4) “live”/“lives”

(5) Name of country of residence

(6) “you”/“she”/“he”

(7) “move”/“moves”

SUS005 Benefits Suspended – Non-Citizen Outside U.S. Over 6 Months (Use with SUS001)

If  (1)   (2)  to the United States for one whole calendar month, we may be able to begin payments. Please contact us if this happens.

Fill-ins:

(1) “you”/“she”/“he”

(2) “return”/“returns”

SUS006 Technical Entitlement – Auxiliary Claim SD

We are stopping the benefits  (1)  been receiving as a  (2)  on  (3)  Social Security record. This is because  (4)  entitled to an equal or larger benefit on  (5)  record.

Fill-ins:

(1) “you have”/“she has”/“he has”

(2) Type of benefit

(3) NH-NAME (possessive)

(4) “you are”/“she is”/“he is”

(5) “your own/her own/his own/another person's”

SUS014 Benefits Suspended – No Child in Care

We cannot pay  (1)  because  (2)  not taking care of a child who  (3)  entitled to Social Security benefits.

Fill-ins:

(1) SN/“you”

(2) ““you are”/“she is”/“he is”/“you were”/“she was”/“he was”

(3) “is”/“was”

SUS017 Benefits Stopped Due to Work

We cannot pay  (1)  because of  (2)  work.

Fill-ins:

(1) SN/“you”

(2) “your”/“her”/“his”

SUS018 Beneficiary or Spouse Entitled to Another GPO

We cannot pay  (1)  because two-thirds the amount of  (2)  government pension is equal to or larger than  (3)  monthly Social Security benefit.

Fill-ins:

(1) SN/“you”

(2) “your”/“her”/“his”

(3) “your”/“her”/“his”

SUS021 S8 Award Notice – Beneficiary Non-DAA (Follows CHKC11)

When we begin your  (1)  payments, you will be paid all money that is due you. When we make a decision about your payee, we will send you another letter. This letter will explain what you can do if you disagree with our payee decision.

Fill-in:

(1) Social Security

SUS022 S8 Award Notice – Beneficiary DAA

We will begin your disability payments when we select a payee for you. We will send your payee all money due you. Before we begin payments, we will send another letter telling you whom we selected as your payee. This letter will explain what you can do if you disagree with the payee we selected.

SUS026 S8 Award Notice – Beneficiary Non-DAA

We have determined that you need help managing your payments. We will be selecting a qualified person to receive your payments. We call this person a representative payee. It will be your payee's duty to manage your  (1)  payments for you and use them for your needs.

Fill-in:

(1) Social Security

SUS029 Lead-in Statement – Multiple Suspensions Multiple Periods

We cannot pay  (1)  for  (2)   (3)   (4)  and  (5)   (6)   (7)   (8)  .

Fill-ins:

(1) SN/“you”

(2) Month and year

(3) “and”/“through”/null

(4) Month and year/null

(5) “beginning”/null

(6) Month and year

(7) “and”/“through”/null

(8) Month and year/null

SUS030 Lead-in Statement – Multiple Suspensions Multiple Periods

We cannot pay  (1)  for  (2)   (3)   (4)  ,  (5)   (6)   (7)  and  (8)   (9)   (10)   (11)  .

Fill-ins:

(1) SN/“you”

(2) Month and year

(3) “and”/“through”/null

(4) Month and year/null

(5) Month and year

(6) “and”/“through”/null

(7) Month and year/null

(8) “beginning”/null

(9) Month and year

(10) “and”/“through”/null

(11) Month and year/null

SUS031 Lead-in Statement – Multiple Suspensions Multiple Periods

We cannot pay  (1)  for  (2)   (3)   (4)  ,  (5)   (6)   (7)  ,  (8)   (9)   (10)  and  (11)   (12)   (13)   (14)  .

Fill-ins:

(1) SN/“you”

(2) Month and year

(3) “and”/“through”/null

(4) Month and year/null

(5) Month and year

(6) “and”/“through”/null

(7) Month and year/null

(8) Month and year

(9) “and”/“through”/null

(10) Month and year/null

(11) “beginning”/null

(12) Month and year

(13) “and”/“through”/null

(14) Month and year/null

SUS057 Alien Not Lawfully Present – Initial No Pay Award

Even though we cannot pay  (1)  benefits, we may be able to pay other individuals if they are entitled on this record.

Fill-in:

(1) “you”/beneficiary full name

SUS060 Number Holder Suspension – Alien Deportation

We cannot pay  (1)  benefits beginning  (2)  because  (3)  been deported. Please let us know if  (4)  permitted to stay in the United States as a resident, because we may be able to pay  (5)  benefits again.

Fill-ins:

(1) SN/“you”

(2) DOST in format “May 1993”

(3) “you have”/“she has”/“he has”

(4) “you are”/“she is”/“he is”

(5) “you”/“her”/“him”

SUS063 Lawful Alien Status Needs Reverification

Based on the information we have,  (1)  lawfully present status will end  (2)  . To receive benefits after that date,  (3)  must give us new evidence by  (4)  about  (5)  status. This evidence must show that  (6)  status has been extended or changed to another lawfully present category. If we do not receive this evidence by  (7)  , we will stop  (8)  benefits.

Fill-ins:

(1) “your”/beneficiary's full name, possessive

(2) date in the format Month DD, YYYY

(3) “you”/“she”/“he”

(4) date in the format Month DD, YYYY

(5) “your”/ “her”/“his”

(6) “your”/“her”/“his”

(7) date in the format Month DD, YYYY

(8) “your”/“her”/“his”

SUS064 Alien Not Lawfully Present – Initial No Pay Award

Based on the information we have,  (1)  not meet the above requirement. We may begin to pay  (2)  benefits if  (3)  alien status changes or if  (4)  the U.S. We will send another letter if we begin  (5)  benefits.

Fill-ins:

(1) “you do”/beneficiary's full name plus “does”

(2) “you”/“her”/“him”

(3) “your”/“her”/“his”

(4) “you leave”/ “she leaves”/ “he leaves”

(5) “your”/“her”/“his”

SUS065 Alien Status

Under the law, we  (1)  pay  (2)  for  (3)  any month  (4)  lawfully present in the U.S. To receive benefits,  (5)  must be a U.S. citizen or national, or lawfully present in the U.S., defined by the Attorney General as an alien;

lawfully admitted for permanent residence;

admitted as a refugee under section 207 of the Immigration and Nationality Act (INA);

granted asylum under section 208 of the INA;

paroled under section 212(d)(5) of the INA (except for aliens paroled for an exclusion hearing or prosecution in the U.S.);

an alien whose deportation has been withheld under section 243 (h) of the INA as in effect prior to April 1, 1997, or whose removal has been withheld under section 241(b)(3) of the INA.

granted conditional entry as a refugee under section 203(a)(7) of the INA as in effect prior to April 1, 1980;

inspected and admitted to the U.S. and who has not violated the applicable terms of his/her status;

with a pending application for political asylum under section 208 of the INA or a pending application for withholding of deportation under section 243(h) of the INA, and employment authorization; or

belonging to any specific class of aliens permitted to remain in the U.S. under U.S. law or policy, for humanitarian or other public policy reasons.

Fill-ins:

(1) “can”/“cannot”

(2) “you”/beneficiary's full name

(3) null

(4) ““you are”/“she is”/ “he is”/you are not/she is not/he is not”

(5) “you”/“she”/“he”

SUS066 Auxiliary Benefits Suspended Pending Development of the Number Holder's CDR Investigation

We cannot pay benefits  (1)   (2)  so we can study the facts and decide whether  (3)  still meets the requirements to receive disability benefits. We will let you know when we make this decision and will tell you whether we can start  (4)  benefits again.

Fill-ins:

(1) “beginning”

(2) MMYYYY

(3) NH-Name

(4) BGN possessive/BGN plus BLN possessive/“your”

SUS069 Notify the Disabled Claimant that His/Her Benefits are being Suspended Pending Development for a Continuing Disability

We cannot pay  (1)  benefits because our records show that  (2) 

did not return information we asked for; or

 (3)  returned to work; or

 (4)  health improved; or

 (5)  could not be located.

We cannot pay benefits because we must study the facts and decide whether  (6)  still  (7)  the requirements to receive disability benefits.

Fill-ins:

(1) BGN plus BLN/”you”

(2) “he”/“she”/“you”

(3) “he”/“she”/“you”

(4) “his”/“her”/“your”

(5) “he”/“she”/“you”

(6) “he”/“she”/“you”

(7) “meets”/ “meet”

SUS070 Benefits Suspended Pending Development of Correct Address or Beneficiary's Whereabouts Unknown

We cannot pay  (1)  starting  (2)  . We need more information before we can start  (3)  payments again.

Fill-ins:

(1) “you”/FN

(2) Date (Month and Year)

(3) “your”/ “his”/ “her”

SUS077 Ongoing Voluntary Suspension to Earn Delayed Retirement Credits (VOLDRC or LEGIS1)

We received  (1)  request to suspend  (2)  retirement benefits to earn delayed retirement credits. Suspending these benefits will also stop payments to  (3)  on any other record on which  (4)  entitled. We will restart  (5)  benefits with the earlier of:

  • The month  (6)  age 70, or

  • The month after  (7)  for payments to restart.

Fill ins:

(1) “your”/ Number holder's BGN plus BLN (possessive)

(2) “your”/”his”/ “her”

(3) “you”/”him”/ “her”

(4) “you are”/ “he is”/ “she is”

(5) “your”/ Number holder's BGN plus BLN (possessive)

(6) “you reach”/ “he reaches”/ “she reaches”

(7) “you ask”/ “he asks”/ “she asks”

SUS079 Beneficiary Requests Waiver of His Right to Benefit Payments

We are withholding  (1)  benefits because  (2)  requested us to do so.

Fill-ins:

(1) BGN plus BLN possessive/”your”

(2) “he has”/“she has”/“you have”

SUS081 Beneficiary's Benefits Will be Suspended because of an Administrative Sanction

We notified  (1)  earlier that we would withhold some benefits if  (2)  became entitled to Social Security benefits. Under Social Security rules we will not pay a person Social Security benefits for a certain period of time if that person:

Made a statement or presented a material fact that the person knew or should have known was false or misleading, and we used the information to decide entitlement or payment amounts; or

Omitted material facts that the person knew or should have known we needed when we decided entitlement or payment amounts.

When we do not pay the person, we call this a penalty. As a result we are withholding  (3)  benefits from  (4)  through  (5)  .

Fill-ins:

(1) Ms. Plus BLN/Mr. plus BLN/ BGN/BGN plus BLN/”you”

(2) “she”/“he”/“you”

(3) “her”/“his”/“your”

(4) Month YYYY

(5) Month YYYY

SUS084 Embedded Period of Voluntary Suspension to Earn Delayed Retirement Credits (VOLDRC or LEGIS1)

We received  (1)  request to suspend  (2)  retirement benefits for  (3)  to earn delayed retirement credits. Suspending these benefits will also stop payments to  (4)  on any other record on which  (5)  entitled. We will restart  (6)  benefits for  (7)  in  (8)  unless  (9)  us to restart  (10)  benefits earlier.

Fill-ins:

(1) “your”/ Number holder's BGN plus BLN (possessive)

(2) “your”/ “his”/ “her”

(3) Month CCYY/ Month CCYY through Month CCYY

(4) “you”/ Number holder's name BGN plus BLN (not possessive)

(5) “you are”/ “he is”/ “she is”

(6) “your”/ Number holder's name BGN plus BLN (possessive)

(7) Month CCYY of restart of benefits

(8) Month CCYY of first payment after restart of benefits

(9) ”you ask”/ “he asks”/ “she asks”

(10) “your”/ “his”/ “her”

SUS085 Suspension of Benefits Due to Alien Deportation or Removal from the U.S. – Number Holder

We cannot pay  (1)  benefits beginning  (2)  because  (3)  been deported or removed from the United States under one of the following sections of the Immigration and Nationality Act (INA):

Section 241(a) of the INA in effect prior to April 1, 1997;

Section 237(a); or

Section 212(a)(6)(A).

Please let us know if in the future  (4)  permitted to return to the United States as a lawful permanent resident. We may be able to pay  (5)  benefits at that time.

Fill-ins:

(1) Ms. Plus BLN/Mr. plus BLN/ “you”

(2) Show the DOST in the format Month, YYYY

(3) “she has”/“he has”/“you have”

(4) “she is”/“he is”/ “you are”

(5) “her”/“him”/ “you”

SUS086 Suspension of Auxiliary/Survivor Benefits Due to Number Holder's Alien Deportation or Removal from the U.S.

No benefits are payable to  (1)  beginning  (2)  because  (3)  has been deported or removed from the United States.

Benefits may be payable if  (4)   (5)  a U.S. citizen or  (6)   (7)  in the United States for a full calendar month or more without leaving for any period, no matter how short. Please let us know if either of these things happen.

Fill-ins:

(1) Beneficiary's given name (BGN)/ plus BLN/”you”

(2) Show the DOST in the format Month, YYYY

(3) Show the NH's full name

(4) BGN/BGN plus BLN/”you”

(5) “becomes”/ “become”

(6) “she”/ “he”/ “you”

(7) “stays”/ “stay”

SUS100 Suspension of Auxiliary's Benefits – Number Holder (NH) Requests Voluntary Suspension to Earn Delayed Retirement Credits (LEGIS1)

We received  (1)  request to suspend  (2)  benefits to earn delayed retirement credits. As a result, we must suspend the benefits  (3)  on  (4)  record. We will restart  (5)  benefits with the earlier of:

  • The month  (6)  reaches age 70, or

  • The month after  (7)  asks for payments to restart.

Fill-ins:

(1) Number holder's BGN plus BLN (possessive)

(2) “his”/ “her”

(3) “you receive”/Auxiliary's BGN plus BLN (not possessive) plus “receives”

(4) Number holder's BGN plus BLN (possessive)

(5) “your”/Auxiliary's BGN plus BLN (possessive)

(6) Number holder's BGN plus BLN (not possessive)

(7) Number holder's BGN plus BLN (not possessive)

TAXC01 CAPTION

Living In A Foreign Country Affects Benefits

TAXC04 CAPTION

Your Benefits May Be Taxed

TAXD01 Dictated Text

TAX002 Alien Tax Withheld

We will withhold federal income tax from  (1)  benefit each month starting  (2)  .

If  (3)  a U.S. resident, please let us know and we will stop withholding the tax.

The United States has income treaties with Canada, Egypt, Germany, India, Ireland, Israel, Italy, Japan, Romania, Switzerland and the United Kingdom that may reduce or eliminate this tax on Social Security benefits for certain residents of these countries. Please contact the Internal Revenue Service to learn more about these treaties. Please contact us to stop or reduce the tax if  (4)  the conditions of an income tax treaty.

Fill-ins:

(1) “your”/”beneficiary's full name, possessive”

(2) date in the format Month CCYY

(3) “you become”/”he becomes”/”she becomes”

(4) “you meet”/“he meets”/“she meets”

TAX003 Alien Tax Withheld

We use information about  (1)  citizenship and residency to decide whether to withhold federal income tax from  (2)  benefits. If you think we have wrong information, please contact us.

We collect this tax for the Internal Revenue Service (IRS). If you have questions about this tax, or to learn about  (3)  or appeal rights, please contact the IRS.

Fill-ins:

(1) “your”/”beneficiary's full name, possessive”

(2) “your”/”his”/”her”

(3) “your”/“beneficiary's full name, possessive”

TAX028 Notification of Potential Tax Liability

You may have to pay taxes on the benefits you get from us. Part of your Social Security benefits may be taxed if:

  • you are single and your total income is more than $25,000 or

  • you are married and you and your spouse have total income of more than $32,000.

You can decide if you want to have federal taxes withheld from your benefits. If you want taxes withheld, you need to complete and return a Form W-4V, Voluntary Withholding Request. You can get Form W-4V from the Internal Revenue Service by calling 1-800-829-3676. You can also get this form at  (1)  on our website. After you complete and sign the form, return it to your local Social Security office by mail or in person.

You can find more information on paying taxes in the enclosed pamphlet,  (2)  .

Fill-ins:

(1) www.social security.gov/planners/taxes.htm

(2) “What You Need To Know When You Get Social Security Disability Benefits”/“What You Need to Know When You Get Retirement or Survivors Benefits”

TER001 Terminated – Not Student/Not Disabled

 (1)   (2)  no longer entitled to Social Security benefits beginning  (3)  .  (4)  benefits are stopping because in that month  (5)  :

 (6)  years old, and

not disabled, and

not a full-time elementary or secondary level school student.

Fill-ins:

(1) SN/“You”

(2) “is”/“are”

(3) Month of termination, in format “June 1991”

(4) “your”/“her”/“his”

(5) “you are”/ “she is”/ “he is”

(6) “18”/“19”

TER002 Terminated – No Longer Student

 (1)   (2)  no longer entitled to Social Security benefits beginning  (3)  .  (4)  benefits are stopping in that month because:

 (5)  not a full-time elementary or secondary level school student and,

 (6)  not disabled.

Fill-ins:

(1) SN/“You”

(2) “is”/“are”

(3) Month of termination in format “June 1991”

(4) “your”/ “her”/ “his”

(5) “you are”/“she is”/“he is”

(6) “you are”/“she is”/“he is”

TER003 Terminated – Student Age 19

 (1)   (2)  no longer entitled to student benefits beginning  (3)  . Student benefits normally end with the payment before the month the student turns 19. But,  (4)  met an exception which allowed benefits to continue past that month. The exception allows benefits to continue for two months after the student turns 19, or until the end of the school term, whichever comes first.

However, if the school requires a student to reenroll each quarter or semester, benefits may continue until that quarter or semester ends.  (5)  no longer  (6)  the exception beginning  (7)  , so  (8)  student benefits end that month.

Fill-ins:

(1) “You”/beneficiary's name

(2) “is”/“are”

(3) Month of termination in format “June 1991”

(4) “you”/“she”/“he”

(5) “you”/“she”/“he”

(6) “meet”/“meets”

(7) Month of termination in format “July 1991”

(8) “your”/“her”/“his”

TER004 Termination of Benefits

 (1)   (2)  not entitled to benefits beginning  (3)  because  (4)  in that month.

Fill-ins:

(1) SN/“You”/beneficiary's name

[4a] “you”/“she”/“he”

(2) “is”/“are”

(3) Month in format “July 1991”

(4)

[4a] “remarried”/“(4b) divorced”/“(4c) married”/“[4d] died”

[4b] “you”/“she”/“he”

[4c] “you”/“she”/“he”

[4d] “she”/ “he”

TER006 Dual Entitlement Benefits Terminate (T5)

 (1)  no longer entitled to benefits beginning  (2)  because  (3)  entitled to an equal or larger benefit on another record.

Fill-ins:

(1) Beneficiary's Name “is”/“You are”

(2) Effective date in format May 1997

(3) “you are”/“she is”/“he is”

TER007 Terminated – No Child in Care

 (1)  no longer entitled to Social Security benefits beginning  (2)  . To be entitled,  (3)  must be taking care of a child who is entitled to benefits. That child must be under age 16 or disabled. In  (4)  ,  (5)  child  (6)   (7)  .

Fill-ins:

(1) “you are”/“she is”/“he is”

(2) Month of termination in format “July 1991”

(3) “you”/“she”/“he”

(4) Month of termination in format “July 1991”

(5) “your”/“her”/“his”

(6) child's name

(7) “got married”/“died”/”became age 16”/”was no longer entitled to disability benefits”

TOT004 U.S. Benefit Based on U.S. Credits Alone

 (1)  for benefits using work covered by the U.S. only. Under our agreement with  (2)  , no U.S. benefits may be paid using work covered by  (3)  if  (4)  for benefits without it.

Fill-ins:

(1) “You qualify”/Ms. plus NH-last name plus “qualifies/Mr. plus NH-last name plus “qualifies”

(2) Name of the country(ies) in one of the following formats: “Country”/“Country and Country”/“Country, Country and Country”/“Country, Country, Country and Country”

(3) Name of the country(ies) in one of the following formats: “Country”/“Country and Country”/“Country, Country and Country”/“Country, Country, Country and Country”

(4) “you qualify”/ “she qualifies”/ “he qualifies”

TOTR04 U.S. Benefit Based on U.S. Credits Alone

 (1)  for benefits using work covered by the U.S. only. Under our agreement with  (2)  , no U.S. benefits may be paid using work covered by  (3)  if  (4)  for benefits without it.

Fill-ins:

(1) “You qualify”/Ms. plus NH-last name plus “qualifies”/Mr. plus NH-last name plus “qualifies”

(2) Name of the country(ies) in one of the following formats: “Country”/“Country and Country”/“Country, Country and Country”/Country, Country, Country and Country”

(3) Name of the Country(ies) in one of the following formats: “Country”/“Country and Country”/“Country, Country and Country”/“Country, Country, Country and Country”

(4) “you qualify”/ “she qualifies”/ “he qualifies”

TOT005 Introductory Statement When the Beneficiary is being Denied for a Factor of Entitlement other than Insured Status and also When the Claimant is being Denied and the Decision Applies to Both Regular and Totalization Benefits

This decision applies to  (1)  claim for both regular U.S. benefits and U.S. benefits under the Social Security agreement with  (2)  .

Fill-ins:

(1) “your”/beneficiary's full name, possessive

(2) Name of the country(ies) in one of the following formats: “Country”/“Country and Country”/“Country, Country and Country”/“Country, Country, Country and Country”

TOT006 Disallowed Both Regular and Totalization Benefits

 (1)  at least six credits under the U.S. Social Security program before we can give  (2)  credit for coverage in another country. Since  (3)  less than six U.S. credits, we did not count any credits in  (4)  .

Fill-ins:

(1) “You need”/Ms. plus NH-last name plus “needs”/Mr. plus NH-last name plus “needs”

(2) “you”/“her”/“him”

(3) “you have”/“she has”/“he has”

(4) Name of the country(ies) in one of the following formats: “Country”/“Country and Country”/“Country, Country and Country”/“Country, Country, Country and Country”

TOT007 Disallowed Claim – Foreign Credits were not Yet Considered

We based our decision on  (1)  U.S. work credits. We did not look at the work credits  (2)  may have earned in  (3)  .  (4)  may still be eligible for U.S. Social Security retirement benefits based on combined U.S. and foreign credits. We will send  (5)  another letter after we consider foreign work credits.

Fill-ins:

(1) “your”/FN possessive

(2) “you”/FN

(3) Name of the country(ies) in one of the following formats: “Country”/”Country and Country”/”Country, Country and Country”/”Country, Country, Country and Country”

(4) “You”/FN

(5) “you”/FN

TOT008 Disallowance for Paid Benefits because Beneficiary has not Worked Long Enough Under U.S. Social Security

 (1)  not worked long enough to qualify for benefits covered by the U.S. Social Security program. We will work with  (2)  to determine any work credits  (3)  earned in  (4)  . When we know the number of foreign credits earned, we will send  (5)  a separate notice to let  (6)  know if  (7)  eligible for U.S. benefits based on combined U.S. and foreign credits.

Fill-ins:

(1) “You have”/FN plus “has”

(2) Name of country(ies) in one of the following formats: “Country”/“Country and Country”/“Country, Country and Country”/“Country, Country, Country and Country”

(3) “you”/FN

(4) Name of country(ies) in one of the following formats: “Country”/“Country and Country”/“Country, Country and Country”/“Country, Country, Country and Country

(5) “you”/FN

(6) “you”/FN

(7) “you are”/FN plus “is”

TOT010 Claimant has also Filed for Benefits from a Foreign Country

 (1)  application is also a claim for social insurance benefits from  (2)  .  (3)  will let you know if  (4)  for benefits under  (5)  laws.

Fill-ins:

(1) Your/Ms. plus beneficiary's last name, possessive/Mr. plus beneficiary's last name, possessive/beneficiary's given name, possessive/beneficiary's full name, possessive

(2) Name of country(ies) in one of the following formats: “Country”/“Country and Country”/“Country, Country and Country”/“Country, Country, Country and Country”

(3) That country/Those countries

(4) “you qualify”/“she qualifies”/“he qualifies”

(5) “its”/“their”

TWPR01 Trial Work Period and Work Continuing

The Social Security law provides a trial work period so that  (1)  can test  (2)  ability to work, despite  (3)  impairment, without losing benefits. The trial work period may last as long as 9 months in which  (4)   (5)  for earnings of more than $  (6)  a month or  (7)  self-employment earnings of $  (8)  a month or spend more than 80 hours a month in self-employment. These 9 trial work service months, as they are called, may be consecutive or they may be separated by months in which  (9)  not working at all.

According to the information reported to us,  (10)  ninth service month will be  (11)  . At that time you will be contacted for further information about  (12)  work and the amount of earnings.  (13)  case will then be reviewed to see whether  (14)  still disabled within the meaning of the law. A person's disability ends if  (15)  becomes able to do substantial gainful work. [At the present time, earnings over $  (16)  a month will be considered substantial and gainful.] If it is determined that  (17)  still disabled,  (18)  benefits will continue. If  (19)  disability ends,  (20)  will receive benefits for an additional 3 months. The law also provides that entitlement to disability benefits shall end if it is determined that an individual's medical condition is no longer severe enough to prevent  (21)  from working. In such cases, the trial work period ends upon recovery. However, even if the trial work period is thus ended  (22)  will receive 3 additional months benefits.

Fill-ins:

(1) FN/“you”

(2) “your”/“her”/“his”

(3) “your”/“her”/“his”

(4) “you”/“she”/“he”

(5) “work”/“works”

(6) Money amount *

(7) “have”/“has”

(8) Money amount *

(9) “you are”/“she is”/ “he is”

(10) FN, possessive/your

(11) 9 TWP service month/year *

(12) “your”/“her”/“his”

(13) “your”/“her”/“his”

(14) “you are”/“she is”/ “he is”

(15) “she”/“he”

(16) Current SGA amount *

(17) “you are”/“she is”/“he is”

(18) “your”/“her”/“his”

(19) “your”/“her”/“his”

(20) “you”/“she”/“he”

(21) “her”/“him”

(22) “you”/“she”/“he”

(*) indicates that the fill-in is manual

TWPR02 Trial Work Period and Work Ceased

The Social Security law provides a trial work period so that  (1)  can test  (2)  ability to work, despite  (3)  impairment, without losing benefits. The trial work period may last as long as 9 months in which  (4)   (5)  for earnings of more than $  (6)  a month or  (7)  self-employment earnings of $  (8)  a month or spend more than 80 hours a month in self-employment. These 9 trial work service months, as they are called, may be consecutive or they may be separated by months in which  (9)  not working at all. At the end of these 9 months, a person's case is reviewed to see whether  (10)  is still disabled within the meaning of the law. Disability ends if a person becomes able to do substantial gainful work. [At the present time, earnings over $  (11)  a month will be considered substantial and gainful.] If it is determined that a person is still disabled, benefits will continue. If disability ends, benefits will be paid 3 additional months.

The law also provides that entitlement to disability benefits shall end if it is determined that an individual's medical condition is no longer severe enough to prevent  (12)  from working. In such cases, the trial work period ends upon recovery. However, even if the trial work period is thus ended, benefits will be paid for 3 additional months.

The information reported to us shows that  (13)  worked in  (14)   (15)  of  (16)  trial work period. You should notify us promptly if you believe that  (17)  recovered from  (18)  disability or  (19)  returned to any type of work.

Fill-ins:

(1) FN/“you”

(2) “your”/“her”/“his”

(3) “your”/“her”/“his”

(4) “you”/“she”/ “he”

(5) “work”/“works”

(6) Money amount *

(7) “have”/“has”

(8) Money amount *

(9) “You do”/“She does”/ “He does”

(10) “she/he”

(11) Current SGA amount *

(12) “her/him”

(13) “you”/“she”/“he”

(14) TWP elapsed service months in format “9” *

(15) “month”/“months”

(16) your/“her”/“his”

(17) “you have”/“she has”/“he has”

(18) “your”/“her”/“his”

(19) “you”/“she”/“he”

(*) indicates that the fill-in is manual

VRN005 State Vocational Rehabilitation Services are Available (All DIB Denials)

If you want to ask about counseling, training, and other services to help you in going to work, contact the nearest State vocational rehabilitation office. Their phone number is in the blue pages of your telephone book under State Government. You can also go to our Office of Employment Support Programs' website at  (1)  . Click on the State where you live and it will provide your local vocational rehabilitation agency's address and telephone number.

VRN006 Referral to a State Agency for Vocational Rehabilitation Services

A vocational rehabilitation or employment services provider may contact  (1)  to help  (2)  in going to work. The provider may be from a State agency or work under contract with Social Security.

If  (3)  to work, we have special rules that let us continue  (4)  cash payments and health care coverage. To learn more about how work and earnings affect disability benefits, visit our website at  (5)  .

 (6)  may also call or visit any Social Security office to ask for the following publications:

  • Social Security - Working While Disabled...How We Can Help (SSA Publication No. 05-10095); and

  • Social Security - If You Are Blind--How We Can Help (SSA Publication No. 05-10052).

Fill-ins:

(1) “you”/FN

(2) “you”/“him”/“her”

(3) “you go”/FN plus “goes”

(4) “your”/“his”/“her”

(5) www.socialsecurity.gov/work/

(6) “You”/“He”/“She”

VTW001 General (Beneficiary's Requested Start Dates and Rates)

You asked that we withhold money from  (1)  benefits for voluntary Federal tax withholding. You want  (2)   (3)   (4)   (5)   (6)   (7)   (8)   (9)   (10)   (11)   (12)   (13)   (14)   (15)   (16)   (17)   (18)   (19)  .

Fill-ins:

(1) “your”/Beneficiary's Name possessive

(2) 7 percent/15 percent/28 percent/31 percent/null

(3) “withheld”/null

(4) “beginning”/“for”/null

(5) Date in the format September 1995/null

(6) “and”/“through”/null

(7) Date in the format September 1995/null

(8) “,”/and/null

(9) 7 percent/15 percent/28 percent/31 percent/null

(10) “withheld”/null

(11) “beginning”/“for”/null

(12) Date in the format September 1995/null

(13) “and”/“through”/null

(14) Date in the format September 1995/null

(15) “and”/null

(16) 7 percent/15 percent/28 percent/31 percent/null

(17) “withheld”/null

(18) “beginning”/null

(19) Date in the format September 1995/null

VTW002 Start Withholding (Current Benefits)

We will withhold $  (1)  from  (2)  benefit for  (3)  . Thereafter, we will withhold $  (4)  each month.  (5)   (6) 

Fill-ins:

(1) Money fill-in

(2) “your”/Beneficiary's Name possessive

(3) Date fill-in

(4) Money fill-in

(5) “We will continue to withhold until”/null

(6) Date fill-in/null

VTW003 Voluntary Tax Withholding from PMA

We will withhold $  (1)  from  (2)  next check. This check is the money  (3)  due through  (4)  .

Fill-ins:

(1) Money fill-in

(2) “your”/Beneficiary's Name possessive

(3) “you are”/“she is”/ “he is”

(4) Date fill-in

VTW004 Stopped Withholding but Resume in Future

We will not withhold money for voluntary Federal tax withholding from  (1)  monthly Social Security benefits beginning  (2)  through  (3)  .

Fill-ins:

(1) “your”/Beneficiary's Name possessive

(2) Date fill-in

(3) Date fill-in

VTW005 Not Enough for Withholding

Since the amount due  (1)   (2)   (3)  is not enough for voluntary Federal tax withholding, we cannot honor your request.

Fill-ins:

(1) “you”/Beneficiary's Name

(2) “through”/“for”/“from”/null

(3) Date fill-in

VTW006 Stopped Withholding

As you asked, we will stop voluntary Federal tax withholding from  (1)  monthly Social Security benefit beginning  (2)  .

Fill-ins:

(1) “your”/Beneficiary's Name possessive

(2) Date fill-in

WCPC01 Caption

Other Disability Payments Affect Benefits

WCP001 WC/PDB –Number Holder Expressed Intent to File for WC/PDB

We learned that  (1)  to file a claim for workers' compensation or public disability benefit. If  (2)  these payments, we may have to reduce  (3)  Social Security benefits.

At that time,  (4)  may have to pay back any Social Security benefits that  (5)  not due. If  (6)  a claim, please tell us the decision made on the claim right away.

Fill-ins:

(1) NH FN “plans”/“you plan”

(2) “you receive”/“he receives”/“she receives”

(3) “your”/“your and your family's”/“his and his family's”/“her and her family's”/“his”/“her“

(4) “you”/“you and your family”/“he”/“he and his family”/“she“/“she and her family”

(5) “you were”/“he was”/“she was”/“you and your family were”/“he and his family were”/“she and her family were“

(6) “you file”/“he files”/“she files”

WCP003 WC/PDB –Definition of WC/PDB Offset

We have to consider workers' compensation and/or public disability payments when we figure a Social Security benefit. The following will explain how these payments affect Social Security benefits. For more information, please read the enclosed pamphlet, “How Workers' Compensation and Other Disability Benefits May Affect Your Social Security Benefit.”

WCP004 WC/PDB –Number Holder Receiving WC/PDB – No Offset

 (1)  present  (2)  payments of $  (3)  do not affect  (4)  Social Security benefits.

Fill-ins:

(1) NH FN possessive/“Your”

(2) “workers' compensation”/“public disability”/“workers” compensation and public disability”

(3) Money amount

(4) “your”/“you and your family's”/“his”/“his and his family's”/“her”/“her and her family's”

WCP005 WC/PDB –Offset Determined by ACE

The pamphlet explains how we reduce  (1)  Social Security disability benefits. We add the money  (2)  would receive from us and from  (3)  . When this total adds up to more than 80 percent of  (4)  average current monthly earnings, we reduce  (5)  Social Security disability benefits. We found that 80 percent of  (6)  average current monthly earnings is  (7)  .

Fill-ins:

(1) “your”/“your and your family's”/“your family's”/“NH name possessive”/“NH name “and his family's”/“NH name “and her family's”/“NH's name possessive plus “family's”

(2) “you“/'he”/”she”/“you and your family“/“he and his family”/“she and her family”

(3) “workers' compensation”/“public disability benefit payments”/“workers' compensation and public disability benefit payments”

(4) “your”/”his”/”her”

(5) “your”/“your and your family's”/“your family's”/“her”/”his”/“her and her family's”/“his and his family's”/“her family's”/”his family's”

(6) “your”/”his”/”her”

(7) Money amount

WCPR06 WC/PDB – Amount of Offset Based on Estimate for 1 or More Years High 1

When we figured how much to reduce  (1)  benefits, we used an estimate for part of  (2)  earnings before  (3)  became disabled. According to our records, the year in which  (4)  earned the most money between  (5)  and  (6)  was  (7)  . We estimated  (8)  earnings for that year to be $  (9)  . If  (10)   (11)  that this amount is wrong, please let us know.  (12)  will also need to give us any facts  (13)  to show that the amount is wrong.

Fill-ins:

(1) “your”/“your and your family's”/“your family's”/“NH name possessive”/“NH name possessive “and his family's”/“NH name possessive “and her family”/“NH's name possessive plus “family's”

(2) “your”/“her”/“his”

(3) “you”/“she”/“he”

(4) “you”/“she”/“he”

(5) Date of onset minus 5 years in the format “YYYY”

(6) Date of onset in the format YYYY

(7) Year of highest regular earnings in the format “YYYY”

(8) “your”/“her”/“his”

(9) Highest regular earnings in the format “$$$$$.¢¢”

(10) “you”/“she”/“he”

(11) “think”/“thinks”

(12) “you”/“she”/“he”

(13) “you have”/“she has”/“he has”

WCPR07 WC/PDB – Amount of Offset Based on Estimate for 1 or More Years – High 5

When we figured how much to reduce  (1)  benefits, we used an estimate for part of  (2)  earnings before  (3)  became disabled. According to our records, the 5 years in which  (4)  earned the most money were  (5)  to  (6)  . We estimated that  (7)  earned $  (8)  during this period. If  (9)  that this amount is wrong, please let us know.  (10)  will also need to give us any facts  (11)  to show that the amount is wrong.

Fill-ins:

(1) “your”/“your and your family's”/“your family's”/“NH name possessive”/“NH name possessive “and his family's”/“NH name possessive “and her family's”/“NH's name possessive plus “family's”

(2) “your”/“her”/“his”

(3) “you”/“she”/“he”

(4) “you”/“she”/“he”

(5) Year in the format “YYYY” *

(6) Year in the format “YYYY” *

(7) “you”/“she”/“he”

(8) Money amount in the format $$$$$.¢¢ *

(9) “you think”/NH name “thinks”

(10) “you”/“she”/“he”

(11) “you have”/“she has”/“he has”

(*) indicates that the fill-in is manual

WCP007 Number Holder Appealing WC/PDB Decision (Auxiliary Only)

We will not reduce  (1)  benefit because of  (2)   (3)  payments until a decision is made on the appeal of the claim. At that time, we may collect any money that should not have been paid.

Fill-ins:

(1) BGN plus BLN, possessive/your

(2) NH-NAME, possessive

(3) “workers' compensation”/”public disability”/”worker's compensation and public disability”

WCP008 WC/PDB - WC/PDB Claim Pending – Auxiliary Only

If  (1)  receives workers' compensation and/or public disability payments, we may have to reduce  (2)  Social Security benefits. At that time, we may also have to recover any money that should not have been paid.

Fill-ins:

(1) NH name

(2) FN possessive/“your”

WCPR09 WC/PDB — Interim Notice – Pending ACE Determination

We may have to change the amount of  (1)  benefits when we receive proof of the amount of  (2)  average current earnings. We use these earnings to figure how much to deduct from  (3)  benefits.

Fill-ins:

(1) FN possessive/“your”

(2) NH name possessive/“your“/“her”/“his”

(3) “your”/“her”/“his”/FN possessive

WCP009 Number Holder Appealing WC/PDB Decision (Number Holder Only)

We will not reduce  (1)  benefit because of  (2)  payments until  (3)  a decision on  (4)  appeal of the claim. Please let us know the decision on the appeal right away. At that time,  (5)  may have to pay back any Social Security benefits that  (6)  not due.

Fill-ins:

(1) BGN plus BLN possessive/“your”

(2) “workers' compensation”/”public disability benefit”/”worker's compensation and public disability benefit”

(3) “you receive”/“he receives”/“she receives”

(4) “your”/“his”/“her”

(5) “you”/“he”/“she”

(6) “you were”/“he was”/“she was”

WCP010 WC/PDB – Total or Partial WC/PDB Offset – Number Holder Only

We have to take into account  (1)   (2)  of $  (3)   (4)   (5)  when we figure  (6)  Social Security benefits. Due to this payment, we are  (7)   (8)  benefits.

Fill-ins:

(1) your/Numberholder's BGN plus BLN (possessive)

(2) “workers' compensation payment”/“public disability payment”/“workers' compensation and public disability payment”

(3) Money amount

(4) “beginning”/“for”

(5) “Month YYYY”/Month YYYY plus through plus Month YYYY”

(6) “your”/“his”/”her”

(7) “withholding”/“reducing”

(8) “your”/“his”/“her”

WCP011 WC/PDB – Total or Partial Offset – Auxiliary Only

We have to take into account  (1)   (2)  payments when we figure  (3)  Social Security benefits. We are  (4)  the benefits  (5)  due because of these payments.

Fill-ins:

(1) NH name possessive

(2) “workers' compensation”/“public disability”/“workers' compensation and public disability”

(3) FN possessive/“your”

(4) “withholding”/“reducing”

(5) “you are”/“she is”/“he is”

WCP012 WC/PDB –Offset Imposed First Month Number Holder Received DIB and WC/PDB

We are  (1)   (2)  monthly payment beginning  (3)  . This is the first month when  (4)  entitled to Social Security disability benefits and  (5)  payments.

Fill-ins:

(1) “withholding”/“reducing”

(2) null plus FN possessive/”your”

(3) Show the month and year withholding or reduction began in the format “Month YYYY”

(4) “he is”/“she is”/ “you are”

(5) “workers' compensation”/“public disability”/“both workers' compensation and public disability”

WCPR13 WC/PDB Offset Imposed After Date of Notice

We are reducing  (1)  benefits beginning  (2)  because of workers' compensation payments. We must reduce benefits beginning with the month after the month in which we were told about these payments.

Fill-ins:

(1) NH name [possessive]/NH first name possessive/BGN plus BLN possessive/“your”

(2) First month and year of offset in the format “May 1999”

WCP013 Change in Reduction of WC/PDB Due to Change in State Law (Reverse Jurisdiction)

Beginning  (1)  , we are paying  (2)  a Social Security benefit that is not reduced due to  (3)  payments. This is because of a change caused by the State law which provides for the reduction of these payments to persons who receive Social Security disability benefits.

Fill-ins:

(1) Month YYYY

(2) “you”/BGN plus BLN

(3) “worker's compensation”/”public disability”/”workers' compensation and public disability”

WCP014 WC/PDB — Amount of Benefit Received after Offset

 (1)  benefit will be $  (2)  beginning  (3)  .

Fill-ins:

(1) NH first name (possessive)/NH given name plus last name (possessive)/Beneficiary Full name (possessive)/“Your”

(2) Money amount in the format “$$$$.¢¢”

(3) Month of offset in the format “December 1999”

WCPR15 WC/PDB –Number Holder in Offset Due to Receipt of WC/PDB – Adjustment Made

We are  (1)   (2)  benefits beginning  (3)  , when  (4)   (5)  payments changed from $  (6)  to $  (7)  .

Fill-ins:

(1) “withholding”/“reducing”

(2) NH FN possessive/“your”

(3) Date *

(4) “your”/“her”/“his”

(5) “workers' compensation”/“public disability”/“workers' compensation and public disability”

(6) Prior money amount *

(7) Current money amount *

(*) indicates that the fill-in is manual

WCPR16 WC/PDB –Auxiliary in Offset Due to Number Holder Receipt of WC/PDB Adjustment Necessary

We are  (1)   (2)  benefits beginning  (3)  , when the  (4)  payments changed.

Fill-ins:

(1) “withholding”/“reducing”

(2) FN possessive/BGN possessive

(3) Month and year *

(4) “workers' compensation”/“public disability“/“workers' compensation and public disability”

(*) indicates that the fill-in is manual

WCP017 WC/PDB – Increase in Benefit After WC/PDB First Imposed

 (1)  benefits were increased beginning  (2)   (3)   (4)  .  (5)  not reduced because of  (6)  payments.

Fill-ins:

(1) NH SN name (possessive)/BGN plus BLN possessive/BGN possessive/“Your”

(2) Earliest month/year

(3) “and”/null

(4) Month and year/null

(5) “This increase was”/“These increases were”

(6) “workers' compensation”/“public disability”/“workers' compensation and public disability”

WCP018 WC/PDB –Removal of Offset - WC/PDB Terminated

We do not reduce benefits once  (1)  payments have stopped. Therefore, we are paying benefits at the full rate beginning  (2)  . Please let us know right away if  (3)  workers' compensation and/or other public disability payments.

Fill-ins:

(1) “workers' compensation”/ “public disability”/“workers' compensation and public disability”

(2) Month and year in the format “September 1999”

(3) NH name “receives”/“you receive”

WCP019 WC/PDB –Removal of Offset – Number Holder Age 62 or 65 (Before 12/19/2015)

Beginning  (1)  , we are not reducing  (2)  benefits because of  (3)  payments. We do not reduce benefits for months when the disabled worker is age  (4)  or over.

Fill-ins:

(1) Month and year NH attains 65 in format “July 2012”

(2) NH SN possessive/BGN plus BLN possessive/BGN possessive/“your”

(3) “workers' compensation”/“public disability”/“workers' compensation and public disability”

(4) “65”

WCPR20 Workers' Compensation – Lump Sum and Ending Date of Proration

We changed  (1)  monthly benefit because  (2)  received a  (3)  lump-sum award. We treat a lump-sum award as if it were paid on a weekly basis. We  (4)  a full Social Security benefit to  (5)  beginning  (6)  .

Fill-ins:

(1) “Ms.” plus BLN possessive/”Mr.” plus BLN possessive/BGN possessive/null plus FN possessive/“your”

(2) “she”/“he”/“you”/FN

(3) “workers' compensation”/“public disability”/“workers' compensation and public disability”

(4) “will pay”/“started paying”

(5) “her”/“him”/“you”

(6) Month and year in the format March 1999

WCP021 WC/PDB –Possible Excludable Expenses

If  (1)  had any expenses related to  (2)  claim for  (3)  payments, please give us proof that  (4)  paid these expenses. We may be able to deduct some of these expenses when we figure  (5)  Social Security benefits.

Fill-ins:

(1) NH FN/“you”

(2) “your”/”his”/”her”

(3) “workers' compensation”/” workers' compensation and public disability benefit”/ “public disability benefit”

(4) “you”/“he”/“she”

(5) “your and your family's”/“NH name possessive”/ “your family's”/ “ your”/“NH name possessive plus” “and his family's”/“NH name possessive plus” “and her family”/“NH name possessive plus “family's”

WCPR22 WC/PDB – Exclusion of Expenses from WC/PDB Periodic Payments

When we figure how much to reduce  (1)  benefits, we do not count certain medical, legal, or other expenses which were paid out of  (2)   (3)  payments. We excluded  (4)  when we figured  (5)  benefits.

Fill-ins:

(1) “your”/“your and your family's”/“your family's”/“NH name possessive”/“NH name possessive plus “and his family's”/“NH name possessive plus “and her family's”/“NH name possessive plus “family's”

(2) “your”/“her”/“his”

(3) “workers' compensation”/“public disability”/“workers' compensation and public disability”

(4) Actual amount of excludable expenses in format $$$$$.¢¢ *

(5) “your”/“your and your family's”/“your family's”/“NH name possessive”/“NH name possessive plus “and his family's”/“NH name possessive plus “and her family's”/“NH name possessive plus “family's” *

(*) indicates that the fill-in is manual

WCPR23 WC/PDB Offset Based Upon Lump Sum Proration – Method A

 (1)   (2)  received a lump-sum award of $  (3)  to settle  (4)   (5)  claim. A lump-sum award affects Social Security benefits in the same way that periodic payments do. We treat a lump-sum award as if it were paid on a weekly basis.

When we figured how much to reduce  (6)  benefits, we treated the lump sum as if  (7)  had been paid $  (8)  each week. We excluded $  (9)  for legal expenses, and $  (10)  for medical expenses. Based on these facts, we can pay  (11)  benefits for  (12)  through  (13)  . We will reduce  (14)  benefits beginning  (15)  . We will again pay full benefits beginning  (16)  .

Fill-ins:

(1) NH FN/“You”

(2) “have”/“has”

(3) Money amount in the format “$$$$$.¢¢”

(4) “your”/“her”/“his”

(5) “workers' compensation”/“public disability”/“workers' compensation and public disability”

(6) “your”/“your and your family's”/“your family's”/“NH name possessive”/“NH name possessive plus “and his family's”/“NH name possessive plus “and her family's”/“NH name possessive plus “family's”

(7) NH FN/“you”

(8) Money amount in the format “$$$$.¢¢”

(9) Attorney fee amount in the format “$$$$.¢¢”

(10) Amount of medical expenses in the format “$$$$.¢¢”

(11) “you”/“you and your family”/“your family”/“him and his family”/“her and her family”/“him”/“her”/“her family”/“his family”

(12) Month and year of no offset *

(13) Month and year of no offset *

(14) “your”/“your and your family's”/“your family's”/“his and his family's”/“her and her family's”/“his”/“her”/“her family's”/“his family's”

(15) Month and year of no offset *

(16) Month and year of no offset

WCPR24 WC/PDB – Offset Based Upon Lump-Sum Proration – Method B

(*) indicates that the fill-in is manual

 (1)   (2)  received a lump-sum award of $  (3)  to settle  (4)   (5)  claim. A lump-sum award affects Social Security benefits in the same way that periodic payments do. We treat a lump-sum award as if it were paid on a weekly basis.

When we figured how much to reduce  (6)  benefits, we treated the lump sum as if  (7)  had been paid $  (8)  each week. We excluded $  (9)  for legal expenses, medical and other related expenses. For this reason, we lowered the weekly rate from $  (10)  to $  (11)  . This means that we will send  (12)   (13)  benefits beginning  (14)  .  (15)   (16)  .

Fill-ins:

(1) NH FN/“You”

(3) Lump sum gross amount “$$$$$.¢¢”

(2) “have”/“has”

(4) “your”/“her”/”his”

(5) “workers' compensation”/“public disability”/“workers' compensation and public disability”

(6) “your”/“your and your family's”/“your family's”/“NH name possessive”/“NH name plus “and his family's”/“NH name plus “and her family's”/“NH name possessive “family's”

(7) NH FN/“you”

(8) Money amount “$$$$.¢¢”

(9) Total amount of excludable expenses “$$$$.¢¢”

(10) Money amount “$$$$.¢¢”

(11) Money amount “$$$$.¢¢”

(12) “you”/“you and your family”/“your family”/“her”/“him”/“his family”/“her family”/“him and his family”/“her and her family”

(13)” additional”/“partial”/“full” *

(14) Month and year *

(15) “We will pay full benefits beginning [15a]”/null

[15a] Month and year/null (Period is part of fill-in.)

(*) indicates that the fill-in is manual

(16) Lump Sum Ending Date in the format “March 1999”/Null

WCPR25 WC/PDB Offset Based Upon Lump-Sum Proration – Method C

 (1)   (2)  received a lump-sum award of $  (3)  to settle  (4)   (5)  claim. A lump-sum award affects Social Security benefits in the same way that periodic payments do. We treat a lump-sum award as if it were paid on a weekly basis.

When we figured how much to reduce  (6)  benefits, we excluded $  (7)  for legal, medical and other expenses. We treated the rest of the lump sum, $  (8)  , as if  (9)  had been paid $  (10)  per week. We will pay full benefits beginning  (11)  .

Fill-ins:

(1) NH FN/“You”

(2) “have”/“has”

(3) Lump sum gross amount in the format “$$$$$.¢¢”

(4) “your”/“her”/“his”

(5) “workers' compensation”/“public disability”/“workers' compensation and public disability”

(6) “your”/“your and your family's”/“your family's”/“NH name possessive”/“NH name possessive plus “and his family's”/“NH name possessive plus “and her family's”/“NH name possessive “family's”

(7) Sum of attorney and medical expenses in the format “$$$$$.¢¢”

(8) Lump sum which remains in the format “$$$$$.¢¢”

(9) “you”/“she”/“he”

(10) Money amount in the format “$$$$.¢¢”

(11) Lump sum prorated ending date plus one month (month and year full benefits payable) in the format “June 1999”

WCPR27 WC/PDB –Offset Based Upon Unverified Allegation

We may have to change the amount of  (1)  benefits when we receive proof of the amount of  (2)   (3)  payments.

Fill-ins:

(1) FN possessive/“your”

(2) NH name possessive/“his”/“her”/“your”

(3) “workers' compensation”/“public disability”/“workers' compensation and public disability”

WCP028 WC/PDB–Benefits Offset – Number Holder May File for Reduced RIB (NH Age 65 before 12/19/2015)

We may continue to reduce or withhold  (1)  disability benefits until  (2)  age 65. We must take this action because of  (3)   (4)  payments.  (5)  payments do not affect retirement benefits.  (6)  may be eligible for retirement benefits at age 62. To apply, please get in touch with us three months before  (7)  age 62.

Fill-ins:

(1) “your”/“your and your family's”/“ NH name possessive”/“your family's”/“NH name possessive “and his family's”/“NH name possessive “and her family's”/“NH name possessive plus “family's”

(2) “you reach”/”he reaches”/”she reaches”

(3) “your”/”his”/”her”

(4) “workers' compensation”/“ workers' compensation and public disability benefit”/ public disability benefit”

(5) “workers' compensation”/“ workers' compensation and public disability benefit”/ public disability benefit”

(6) “You”/“He”/“She”

(7) “you reach”/“she reaches”/”he reaches”

WCP029 WC/PDB - WC/PDB Claim Pending – Number Holder Only

If  (1)  workers' compensation or public disability benefit payments, we may have to reduce  (2)  Social Security benefits. At that time,  (3)  may have to pay back any Social Security benefits that  (4)  not due. Please let us know the decision on the claim right away.

Fill-ins:

(1) FN “receives”/“you receive”

(2) “your”/“his”/“her”

(3) “you”/“he”/“she”

(4) “you were”/“he was”/“she was”

WCPR31 WC/PDB –Number Holder Appealing WC/PDB –Number Holder and Auxiliary

We will not reduce  (1)  benefit, or the benefits of  (2)  family, because of  (3)  payments until a decision is made on the appeal of  (4)  claim. Please let us know when a final decision is made. At that time, we may collect any money that should not have been paid.

Fill-ins:

(1) NH FN possessive/“your”

(2) “your”/ “her”/ “his”

(3) “workers' compensation”/“public disability”/“workers' compensation and public disability”

(4) “your”/”her”/”his”

WCP032 WC/PDB –Reporting Responsibilities Involving Receipt of WC/PDB – Number Holder

Please let us know right away about any:

Changes in  (1)  workers' compensation or public disability benefit payments.

Lump-sum award(s)  (2)  .

Other payments  (3)  that increase or decrease  (4)  workers' compensation or public disability benefit payments

Fill-ins:

(1) FN/“your”

(2) “you receive”/“he receives”/“she receives”

(3) “you receive”/“he receives”/“she receives”

(4) “your”/”his”/”her”

WCP060 WC/PDB – Removal of Offset – Number Holder Attains FRA

Starting  (1)  , we will stop reducing  (2)  Social Security disability benefits because of  (3)   (4)  payments. We stop reducing disability benefits when  (5)  full retirement age.

Fill-ins:

(1) Month and year NH attains FRA in format “July 2012”

(2) NH name possessive/“your”

(3) “your”/”his”/”her”

(4) “workers' compensation”/“public disability benefit”/“workers' compensation and public disability benefit”

(5) “you reach”/”he reaches”/”she reaches”

WCP061 WC/PDB–Benefits Offset – Number Holder May File for Reduced RIB

We will continue to reduce or withhold  (1)  disability benefits until  (2)  full retirement age in  (3)  . We must take this action because of  (4)   (5)  payments.  (6)   (7)  payments do not affect retirement benefits.  (8)  may be eligible for reduced retirement benefits at age 62. If  (9)  to apply for retirement benefits, please contact us three months before  (10)  age 62.

Fill-ins:

(1) “your”/“NH name possessive”/“your and your family's”/“ your family's”/“NH name possessive “and his family's”/“NH name possessive “and her family's”/“NH name possessive plus “family's”

(2) “you reach”/”he reaches”/”she reaches”

(3) Month and year NH attains FRA in format “July 2012”

(4) “your”/”his”/”her”

(5) “workers' compensation”/“public disability benefit”/” workers' compensation and public disability benefit”

(6) “Your”/“His”/“Her”

(7) “workers' compensation”/“public disability benefit”/” workers' compensation and public disability benefit”

(8) “You”/”He”/”She”

(9) “you decide”/“he decides”/”she decides”

(10) “you reach”/“he reaches”/”she reaches”

WDS001 Work Deductions – No Readjustment

Because  (1)   (2)  not due benefits, benefits to other members of the household should be increased. However, we will pay  (3)  instead of increasing the benefits to other family members. Since this money is really due to other members of the household, it should be used only for their needs.

Fill-ins:

(1) SN/Beneficiary's full name/“you”

(2) “is”/“are”

(3) “you”/”her”/ “him”

WDS002 Benefits to other Family Members in 1/96

Because  (1)   (2)  not due benefits, benefits to other members of the household should be increased. However, for months before January 1996 we will pay  (3)  instead of increasing the benefits to other family members. Since this money is really due the other members of the household, it should be used only for their needs.

For benefits payable beginning January 1996, we can no longer pay you the increase due other family members. We must pay them directly because of a change in the law.

Fill-ins:

(1) “you”/Beneficiary's Name

(2) “are”/“is”

(3) “you”/“him”/“her”

WDS003 Benefit Increase to Non-Working Auxiliaries

We raised  (1)  monthly benefit amount beginning  (2)  because of the work and earnings of another entitled person[s].

Fill-ins:

(1) “your”/Beneficiary's Name possessive

(2) Date

WDWC02 Caption

 (1)  Withdrawal Can Be Cancelled

Fill-in:

(1) SN

WDW006 How to Cancel a Withdrawal

If you change your mind and want to receive these benefits, you may cancel your withdrawal by filing a written request with us. You have up to 60 days after the date of this letter to ask for cancellation. After the 60 days are over, you have to file a new application if you want to receive these benefits. You will not lose any benefits if you cancel your withdrawal within the 60 days.

WDW012 Pre-Adjudicative Withdrawal Approval

We have approved your request to withdraw  (1)  claim for all Social Security  (2)  .

Fill-ins:

(1) FN possessive/“your”

(2)retirement benefits/disability benefits/spouse's benefits/benefits

WEP003 Windfall Elimination Provision is First Applied – Number Holder

We reduced  (1)  Social Security benefits starting  (2)  . This is the first month  (3)  received a pension based on work not covered by Social Security taxes. When  (4)  this type of pension, we may apply the Windfall Elimination Provision to  (5)  Social Security benefits. This changes the way we figure  (6)  benefit amount.  (7)  benefit amount is less than it would be if  (8)  not receiving the pension. To learn more about how non-covered pensions affect Social Security benefits, please see our factsheet titled “Windfall Elimination Provision.” You can get this factsheet at  (9) 

online. You can also call, write, or visit us to get the factsheet.

Fill-ins:

(1) “beneficiary's full name, possessive”/”your”

(2) date in format “Month CCYY”

(3) “you”/“he”/“she”

(4) “you receive”/“he receives”/“she receives”

(5) “your”/”his”/”her”

(6) “your”/”his”/”her”

(7) “Your”/”His”/”Her”

(8) “you were”/“he was”/“she was”

(9) www.socialsecurity.gov/pubs/EN-05-10045.pdf

WEP004 Windfall Elimination Provision no Longer Applies – Number Holder

We changed  (1)  benefit amount starting  (2)  . The Windfall Elimination Provision no longer reduces  (3)  benefits. We stopped applying this provision because  (4)  :

  • Reached 30 years of substantial earnings covered by Social Security taxes, or

  • Stopped receiving a pension based on work not covered by Social Security taxes.

To learn more about how non-covered pensions affect Social Security benefits, please see our factsheet titled “Windfall Elimination Provision.” You can get this factsheet at  (5)  online. You can also call, write, or visit us to get the factsheet.

Fill-ins:

(1) “your”/ “beneficiary's full name, possessive”

(2) date in format “Month CCYY”

(3) “your”/”his”/”her”

(4) “you”/“he”/“she”

(5) www.socialsecurity.gov/pubs/EN-05-10045.pdf

WFO002 Benefits Withheld Pending SSI Offset Computation – Attorney Involved

We are holding  (1)  Social Security benefits for  (2)   (3)   (4)  . We may have to reduce these benefits if  (5)  received Supplemental Income [SSI] for this period. We will not reduce  (6)  past-due benefits if  (7)  did not get SSI benefits for those months.

However, we will withhold part of any past-due benefits to pay  (8)   (9)  . Later in this letter, we will tell you more about the money we are withholding to pay  (10)   (11)  . When we decide how much  (12)  due for this period, we will send you another letter.

Fill-ins:

(1) Mr. plus FN possessive/Ms. plus FN possessive/null plus BGN possessive/null plus FN possessive/“your”

(2) Month and year in format “December 1992”

(3) NULL/“and”/”through”

(4) Month and year in format “January 1992”/NULL

(5) “he”/“she”/“you”

(6) “his”/“her”/“your”

(7) “he”/“she”/“you”

(8) “his”/“her”/“your”

(9) “lawyer”/ “representative”

(10) “his”/ “her”/“your”

(11) “lawyer”/“representative”

(12) “he is”/ “she is”/ “you are”

WFO003 Benefits Withheld Pending SSI Offset – No Attorney (Beginning with Release 3.5.4 WFO003 Replaces WFO001)

We are withholding  (1)  Social Security benefits for  (2)   (3)   (4)  . We may have to reduce these benefits if  (5)  received Supplemental Security Income [SSI] for this period. When we decide whether or not we will have to reduce  (6)  Social Security benefits, we will send  (7)  another letter. We will pay  (8)  any Social Security benefits  (9)  due for this period.

Fill-ins:

(1) “his”/“her”/“your”

(2) Show date in format “January 2012”

(3) null/“and”/“through”

(4) Show date in the format “January 2012”/null/Show date=COM-1 in the format “January 2012”

(5) “he”/“she”/ “you”

(6) “his”/“her”/ “your”

(7) “him”/“her”/ “you”

(8) “him”/ “her”/ “you”

(9) “he is”/“she is”/ “you are”


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900725005
NL 00725.005 - Modernized Claims Systems (MCS) Universal Text Identifiers (UTIs) - 11/14/2017
Batch run: 11/14/2017
Rev:11/14/2017