TN 24 (05-16)

NL 00730.138 “S” Paragraphs and Captions

List of “S” Paragraphs and Captions

A. “SNO” Universal Text Identifiers – Special Notice Option

SNO002 – SPECIAL NOTICE OPTION – USED FOR BRAILLE (3), DATA CD (4), AUDIO CD (6) AND LARGE PRINT (7)

We are sending you this letter in both a standard print version and (1). You will receive them in separate envelopes.

Fill-in values:

 

Fill-in (1)

 

Choice 1

in a Braille version

Choice 2

on a compact disc in Microsoft Word format

Choice 3

on an audio compact disc

Choice 4

a large print version

SNO004 – SPECIAL NOTICE OPTION – USED FOR TELEPHONE CONTACT (2)

As you requested, we will call you within 5 business days of the date of this letter to read it to you.

B. “SSA” Universal Text Identifiers – Headings and Signatures

SSAH28 – DATE AND CLAIM NUMBER

Date: (1)

Claim Number: (2)

Fill-in values:

 

Fill-in (1)

T2R Run Date plus 7 days in the format Month DD, CCYY

Fill-in (2)

9 position numeric SSN plus 1-4 numeric claim symbol

SSAH30 – NAME AND ADDRESS

(1)

(2)

(3)

(4)

(5)

(6)

Fill-in values:

 

Fill-in (1)

Payee Name

Fill-in (2)

Payee Address Line 1

Fill-in (3)

Payee Address Line 2

Fill-in (4)

Payee Address Line 3

Fill-in (5)

Payee Address Line 4

Fill-in (6)

Payee Address Line 5

C. “SUS” Universal Text Identifiers - Suspension

SUSC02 – CAPTION

We May Be Able To Pay (1) Again

Fill-in values:

 

Fill-in (1)

 

Choice 1

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)

Choice 2

You

SUS013 – SUSPENSION HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF WAIVER OF BENEFIT PAYMENTS (WAIVER)

If (1) to receive (2) benefits, we will pay benefits beginning with the month we receive a signed statement from you (3) asking for the benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) plus “decides”

Choice 2

you decide

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

“or” plus Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)

Choice 2

Null

SUS014 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF NO CHILD IN CARE (NOCICS)

We cannot pay (1) because (2) not taking care of a child who (3) entitled to Social Security benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)

Choice 2

you

Fill-in (2)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Choice 4

he was

Choice 5

she was

Choice 6

you were

Fill-in (3)

 

Choice 1

is

Choice 2

are

SUS025 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF PAYEE DEVELOPMENT (DEVPYE) OR DEATH OF PAYEE (DTHPYE) - NO DAA BENEFICIARY OR SUSPENSION HRFST OF PAYEE IS A FUGITIVE FELON (RPFUGF)

The person who received your payments will no longer be your representative payee. We are looking for another qualified person to receive your payments and use them for your needs.

SUS026 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF PAYEE DEVELOPMENT (DEVPYE) - NO DAA BENEFICIARY

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 values:

 

Fill-in (1)

Social Security

SUS027 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF PAYEE DEVELOPMENT (DEVPYE) OR DEATH OF PAYEE (DTHPYE)

When we begin your (1) payments again, you will be paid all the 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 values:

 

Fill-in (1)

Social Security

SUS035 – AUXILIARY SUSPENDED - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF SUSPENSION FOR CDR (DEVDIB) DUE TO NUMBER HOLDER OR AUXILIARY SUSPENDED HRFST OF CDRFTC DUE TO NUMBER HOLDER'S FAILURE TO COOPERATE OR PIC B/E SUSPENDED HRFST OF CDRFTC DUE TO PIC C (CDB) FAILURE TO COOPERATE

We cannot pay further benefits until we can study the facts and decide whether (1) 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 (2) benefits again.

Fill-in values:

 

Fill-in (1)

 

Choice 1

NH-NAME

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) for PIC C with the BCLM-CEC = B (disabled)

Fill-in (2)

 

Choice 1

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)

Choice 2

your

SUS040 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF TREASURY BARRED (BARRED)

We cannot pay (1) benefits because the rules of the United States Treasury Department do not allow payment while (2) (3) in (4). We will let you know if the tax rules change.

Fill-in values:

 

Fill-in (1)

 

Choice 1

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)

Choice 2

you

Fill-in (2)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (3)

 

Choice 1

lives

Choice 2

live

Fill-in (4)

 

Choice 1

Cuba

Choice 2

North Korea

SUS041 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF FOREIGN ENFORCEMENT REPORT NOT RETURNED (FORENF)

We cannot pay (1) benefits because (2) (3) not returned the form, “Report to United States Social Security Administration.” We need the information requested on this form to decide if (4) can receive benefits again.

Fill-in values:

 

Fill-in (1)

 

Choice 1

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)

Choice 2

you

Fill-in (2)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (3)

 

Choice 1

has

Choice 2

have

Fill-in (4)

 

Choice 1

he

Choice 2

she

Choice 3

you

SUS045 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF ENTITLEMENT TO HIGHER BENEFITS ON ANOTHER ACCOUNT (T5NENT) OR TECHNICAL ENTITLEMENT (TECENT)

We cannot pay benefits because (1) (2) eligible for a higher benefit on another record.

Fill-in values:

 

Fill-in (1)

 

Choice 1

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)

Choice 2

you

Fill-in (2)

 

Choice 1

is

Choice 2

are

SUS047 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF GOVERNMENT PENSION OFFSET (GPOOFF)

We cannot pay benefits because (1) (2) eligible for a government pension that is equal to or greater than the monthly Social Security benefit.

Fill-in values:

 

Fill-in (1)

 

Choice 1

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)

Choice 2

you

Fill-in (2)

 

Choice 1

is

Choice 2

are

SUS052 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF DOMESTIC WORK (DOMWRK) OR FOREIGN WORK (FORWRK)

We cannot pay benefits because of (1) work.

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)

Choice 3

NH’s Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)

SUS054 – HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF NON-RESPONDER TO RECONTACT FORM (RECONT) OR TERMINATION BASED ON NON-RESPONSE TO RECONTACT NOTICE (RECONM) FOR PIC E OR PIC C AND NO PAYEE INVOLVED

We cannot pay (1) benefits because (2) (3) not returned the form, SSA-1588 “Beneficiary Recontact Report”. We need the information requested on this form to decide if (4) can receive benefits again.

Fill-in values:

 

Fill-in (1)

 

Choice 1

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)

Choice 2

you

Fill-in (2)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (3)

 

Choice 1

has

Choice 2

have

Fill-in (4)

 

Choice 1

he

Choice 2

she

Choice 3

you

SUS055 – HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF NON-RESPONDER TO RECONTACT FORM (RECONT) OR TERMINATION BASED ON NON-RESPONSE TO RECONTACT NOTICE (RECONM) FOR PIC C AND PAYEE INVOLVED

We cannot pay (1) benefits because (2) (3) not returned the Form SSA-1587 “Beneficiary Recontact Report.” We need the information requested on this form to decide if (4) can receive benefits again.

Fill-in values:

 

Fill-in (1)

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)

Fill-in (2)

 

Choice 1

he

Choice 2

she

Fill-in (3)

 

Choice 1

has

Choice 2

have

Fill-in (4)

 

Choice 1

he

Choice 2

she

SUS068 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF NO CHILD IN CARE (NOCICS)

Please let us know if you are taking care of a child again who is entitled to benefits and under 16 or disabled. We may be able to pay you again.

SUS069 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF SUSPENSION FOR CDR (DEVDIB) (HA, CDB, WIDOW'S DIB) NO DAA

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-in values:

 

Fill-in (1)

 

Choice 1

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)

Choice 2

you

Fill-in (2)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (6)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (7)

 

Choice 1

meets

Choice 2

meet

SUS070 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF WHEREABOUTS UNKNOWN (WHEREU), ADDRESS DEVELOPMENT (DEVADD), AGE DEVELOPMENT (DEVAGE), PENDING DISABILITY DETERMINATION (DISDET), DUAL ENTITLEMENT POTENTIAL WIDOW (CERTEL)

We cannot pay (1) starting (2). We need more information before we can start (3) payments again.

Fill-in values:

 

Fill-in (1)

 

Choice 1

you

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)

Fill-in (2)

Date of Suspension

Fill-in (3)

his

Choice 1

your

Choice 2

his

Choice 3

her

SUS071 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF BARRED (SSA)

We cannot pay benefits because Social Security rules do not allow payment while a beneficiary lives or lived in a barred country.

SUS072 – SUSPENSION LEAD - FOLLOW BY SPECIFIC UTI

Based on the information we have, we cannot pay benefits (1) (2) (3) (4).

Fill-in values:

 

Fill-in (1)

 

Choice 1

beginning

Choice 2

for

Fill-in (2)

 

Choice 1

Date of Suspension or Termination (DOST) that corresponds to the ongoing suspension in the format Month CCYY

Choice 2

NA-HIST-START date in the format Month CCYY

Fill-in (3)

 

Choice 1

and

Choice 2

through

Choice 3

Null

Fill-in (4)

 

Choice 1

NA-HIST-STOP date in the format Month CCYY

Choice 2

Null

SUS073 – RESUMPTION OR REINSTATEMENT OF BENEFITS

Based on the information we have, we can pay benefits (1) (2) (3) (4).

Fill-in values:

 

Fill-in (1)

 

Choice 1

beginning

Choice 2

for

Fill-in (2)

 

Choice 1

First Effective Date (EFD) in History data that corresponds to the reinstatement period

Choice 2

NH-HIST-START date in the format Month CCYY for the embedded reinstatement period

Fill-in (3)

 

Choice 1

and

Choice 2

through

Choice 3

Null

Fill-in (4)

 

Choice 1

NA-HIST-STOP date for the embedded reinstatement period in the format Month CCYY

Choice 2

Null

SUS074 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF NOT LAWFULLY PRESENT (NOTLAW)

We cannot pay (1) benefits because (2) not lawfully present in the U.S.

Fill-in values:

 

Fill-in (1)

 

Choice 1

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)

Choice 2

you

Fill-in (2)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

SUS075 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF NOT A U.S. CITIZEN (NOUSCP)

We cannot pay (1) benefits because (2) not a U.S. citizen.

Fill-in values:

 

Fill-in (1)

 

Choice 1

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)

Choice 2

you

Fill-in (2)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

SUS076 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF LEF U.S. ALIEN SUSPENSION (ALNSUS)

We cannot pay (1) benefits because (2) not a United States citizen and (3) been outside the United States for more than 6 months.

Fill-in values:

 

Fill-in (1)

 

Choice 1

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)

Choice 2

you

Fill-in (2)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (3)

 

Choice 1

has

Choice 2

have

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 at the earlier of:

  • The month (6) age 70, or

  • The month after (7) for payments to restart.

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)

Fill-in (2)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (3)

 

Choice 1

you

Choice 2

him

Choice 3

her

Fill-in (4)

 

Choice 1

you are

Choice 2

he is

Choice 3

she is

Fill-in (5)

 

Choice 1

your

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)

Fill-in (6)

 

Choice 1

you reach

Choice 2

he reaches

Choice 3

she reaches

Fill-in (7)

 

Choice 1

you ask

Choice 2

he asks

Choice 3

she asks

SUS078 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF MONTHLY BENEFIT AMOUNT (MBA) < $1.00 (LESSDO) AND HIB225 OR HIB226 NOT USED

We cannot pay (1) beginning (2) because (3) monthly payment is less than a dollar. At the end of the year, we will adjust (4) record and pay all money (5) due.

Fill-in values:

 

Fill-in (1)

 

Choice 1

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)

Choice 2

you

Fill-in (2)

Effective Date (EFD) in History (HIST) Data on the post-MBR that corresponds to the HRFST LESSDO in format Month CCYY

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

SUS079 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF WAIVER

We are withholding (1) benefits because (2) requested us to do so.

Fill-in values:

 

Fill-in (1)

 

Choice 1

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)

Choice 2

your

Fill-in (2)

 

Choice 1

he has

Choice 2

she has

Choice 3

you have

SUS080 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF PREDATOR (PREDTR)

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-in values:

 

Fill-in (1)

 

Choice 1

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)

Choice 2

you

Fill-in (2)

 

Choice 1

He was

Choice 2

She was

Choice 3

You were

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

he was

Choice 2

she was

Choice 3

you were

Fill-in (6)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

SUS084 – HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF VOLUNTARY SUSPENSION TO EARN DELAYED RETIREMENT CREDIT (VOLDRC or LEGIS1) FOR AN EMBEDDED PERIOD OF SUSPENSION

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-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)

Fill-in (2)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (3)

 

Choice 1

If one month of suspension, show the Effective Date (EFD) in History Data that corresponds to the embedded month of VOLDRC or LEGIS1 suspension in Month CCYY format

Choice 2

If two or more months of suspension, show the first Effective Date (EFD) in History Data that corresponds to the embedded period of VOLDRC or LEGIS1 suspension in Month CCYY format plus the word “through” and ending with the last Effective Date (EFD) in History Data that corresponds to the embedded period of VOLDRC or LEGIS1 in Month CCYY format

Fill-in (4)

 

Choice 1

you

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (non-possessive)

Fill-in (5)

 

Choice 1

you are

Choice 2

he is

Choice 3

she is

Fill-in (6)

 

Choice 1

your

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)

Fill-in (7)

Show the first Effective Date (EFD) in History Data after the embedded period where VOLDRC or LEGIS1 suspension is not present in Month CCYY format

Fill-in (8)

Show the first Effective Date (EFD) in History Data after the embedded period where VOLDRC or LEGIS1 suspension is not present plus one month in Month CCYY format

Fill-in (9)

 

Choice 1

you ask

Choice 2

he asks

Choice 3

she asks

Fill-in (10)

 

Choice 1

your

Choice 2

his

Choice 3

her

SUS087 – PIC A SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF DEPORTATION (DEPORT) – ONGOING OR EMBEDDED PERIOD OF SUSPENSION

We cannot pay (1) benefits because (2) 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);

  • Section 212(a)(6)(A).

This is based on information from the U.S. Department of Homeland Security. Please get in touch with us if in the future (3) permitted to return to the United States as a lawful permanent resident. Benefits may again be payable at that time.

Fill-in values:

 

Fill-in (1)

 

Choice 1

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)

Choice 2

you

Fill-in (2)

 

Choice 1

he was

Choice 2

she was

Choice 3

you were

Fill-in (3)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

SUS088 – AUXILIARY SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF DEPORTATION (DEPORT) – ONGOING OR EMBEDDED PERIOD OF SUSPENSION

No benefits are payable to (1) because (2) was deported or removed from the United States. Please get in touch with us if (3) a U.S. citizen or (4) in the United States for a full calendar month or more without leaving for any period, no matter how short. Benefits may again be payable at that time.

Fill-in values:

 

Fill-in (1)

 

Choice 1

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)

Choice 2

you

Fill-in (2)

NH-NAME

Fill-in (3)

 

Choice 1

BGN plus “becomes”

Choice 2

you become

Fill-in (4)

 

Choice 1

he stays

Choice 2

she stays

Choice 3

you stay

SUS099SUSPENSION – DIRECT DEPOSIT FRAUD

We stopped (1) Social Security benefits because of possible fraud on (2) record. Please contact us right away. We need to verify your direct deposit information before we can resume (3) benefits.

Fill-in values:

Fill-in (1)

 

Choice 1

your

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)

Fill-in (2)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

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-in values:

Fill-in (1)

Number Holder (NH) Beneficiary’s Given Name (BGN) plus Beneficia