TN 26 (08-17)

NL 00730.146 W Paragraphs and Captions

List of “W” Paragraphs and Captions

A. WAV Universal Text Identifiers - Waiver

WAVC03 – CAPTION

If You Think You Should Not Have To Pay Us Back

WAV001 – WAIVER RIGHTS NEW OVERPAYMENT

You have certain rights with respect to this overpayment and its recovery.

  1. Right to Appeal: If you disagree in any way with this overpayment determination, you have the right, within 60 days of the date you receive this notice, to request that the determination be reconsidered. If you request this independent review of the overpayment determination, please submit any additional information you have which pertains to the overpayment.

  2. Right to Request Waiver: You also have the right to request a determination concerning the need to recover the overpayment. An overpayment must be refunded or withheld from benefits unless both of the following are true:

    1. The overpayment was not your fault in any way, and

    2. You could not meet your necessary living expenses if we recovered the overpayment, or recovery would be unfair for some other reason.

If you request waiver, we may need a statement of your assets and monthly income and expenses.

If you request reconsideration and/or waiver within 30 days, the overpayment will not have to be recovered until the case is reviewed. This review is described in more detail on the attached form SSA-3105, Important Information About Your Appeal, Waiver Rights, and Repayment Options. The people in any Social Security office will be glad to help you complete the forms for requesting reconsideration (SSA-561-U2, Request for Reconsideration) and/or waiver (SSA-632-BK, Request for Waiver of Overpayment Recovery or Change in Repayment Options).

Even if you do not want to request reconsideration or waiver, please call, write or visit any Social Security office if you have questions or need more information. Please take this letter with you if you do visit an office.

WAV005 – CROSS PROGRAM RECOVERY FOR SUPPLEMENTAL SECURITY INCOME (SSI) OVERPAYMENT - USED WITH RCY002

You may not have to pay us back. Sometimes we can waive the collection of an overpayment, which means you won't have to pay us back. For us to waive the collection of the overpayment, two things have to be true.

  • It wasn't your fault that you got too much SSI money.

AND

  • Paying us back would mean you can't pay (1) bills for food, clothing, housing, medical care or other necessary expenses, or it would be unfair for some other reason.

If you think these are true about you, contact any Social Security office. You can ask for waiver at any time by completing the waiver form and returning it to us. The form is called Request for Waiver of Recovery or Change in Repayment Rate, Form SSA-632. We will be happy to help you fill out the form. If you ask for waiver after that time, we will stop collecting the overpayment while we decide if we can waive collection.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

B. WCP Universal Text Identifiers – Workers’ Compensation

WCPC01 – CAPTION

Other Disability Payments Affect Benefits

WCP001 – NUMBER HOLDER INTENDS TO FILE FOR WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB)

We learned that (1) to file a claim for workers' compensation or public disability benefits. If (2) these payments, we may have to reduce (3) Social Security benefits.

At that time, (4) may also 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-in values:

 

Fill-in (1)

 

Choice 1

NH-NAME plans

Choice 2

you plan

Fill-in (2)

 

Choice 1

you receive

Choice 2

he receives

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

Choice 4

your and your family’s

Choice 5

his and his family’s

Choice 6

her and her family's

Fill-in (4)

 

Choice 1

you

Choice 2

he

Choice 3

she

Choice 4

you and your family

Choice 5

he and his family

Choice 6

she and her family

Fill-in (5)

 

Choice 1

you were

Choice 2

he was

Choice 3

she was

Choice 4

you and your family were

Choice 5

he and his family were

Choice 6

she and her family were

Fill-in (6)

 

Choice 1

you file

Choice 2

he files

Choice 3

she files

WCP003 – NUMBER HOLDER RECEIVES WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB) PUBLICATION 05-10018

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 Payments May Affect Your Social Security Benefits.”

WCP004 – NUMBER HOLDER RECEIVES WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB) AND MONTHLY BENEFIT AMOUNT (MBA) IS NOT OFFSET

(1) present (2) payments of (3) do not affect (4) Social Security benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

NH-NAME plans

Choice 2

you plan

Fill-in (2)

 

Choice 1

workers' compensation

Choice 2

public disability

Choice 3

workers' compensation and public disability

Fill-in (3)

 

Choice 1

Workers’ Compensation Payment Amounts (WCPD-WC-AMT) in the format $$$$$.¢¢

Choice 2

Public Disability Benefits Amount (WCPD-PDB-AMT) in the format $$$$$.¢¢

Choice 3

Sum of Workers’ Compensation Payment Amounts (WCPD-WC-AMT) plus Public Disability Benefits Amount (WCPD-PDB-AMT) in the format $$$$$.¢¢

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Choice 4

his and his family’s

Choice 5

her and her family’s

Choice 6

your and your family’s

WCP007 – WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB) APPEAL PENDING

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-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)

NH-NAME

Fill-in (3)

 

Choice 1

workers' compensation

Choice 2

public disability

Choice 3

workers' compensation and public disability

WCP008 – TELLS AUXILIARY THAT NUMBER HOLDER INTENDS TO FILE FOR WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB)

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-in values:

 

Fill-in (1)

NH-NAME

Fill-in (2)

 

Choice 1

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

Choice 2

your

WCP009 – NUMBER HOLDER APPEALS WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB)

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-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

workers' compensation

Choice 2

public disability

Choice 3

workers' compensation and public disability

Fill-in (3)

 

Choice 1

you receive

Choice 2

he receives

Choice 3

she receives

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (5)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (6)

 

Choice 1

you were

Choice 2

he was

Choice 3

she was

WCP013 – ADVISES NUMBER HOLDER OF 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-in values:

 

Fill-in (1)

IDET Reverse Jurisdiction Start Date (IDET-RJ-START) in Month CCYY format

Fill-in (2)

 

Choice 1

NH-NAME

Choice 2

you

Fill-in (3)

 

Choice 1

workers' compensation

Choice 2

public disability

Choice 3

workers' compensation and public disability

WCP015 – TRIENNIAL REDETERMINATION (EVERY 3 YEARS)

Based on (1) (2), every 3 years, we check to see if an increase in the national earnings level affects the amount of (3) monthly Social Security benefit. When we checked (4) monthly benefit amount, we found that (5) due more money.

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

workers' compensation payment

Choice 2

public disability payment

Choice 3

workers' compensation and public disability payments

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

WCP016 – MONTHLY BENEFIT AMOUNT (MBA) OFFSET DUE TO WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB) AND COST-OF-LIVING ADJUSTMENT (COLA) DUE

A cost-of-living increase is not reduced because of (1) workers' compensation and/or public disability payments.

Fill-in values:

 

Fill-in (1)

 

Choice 1

NH-NAME (possessive)

Choice 2

your

WCP019 – WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB) STOPS – NUMBER HOLDER AGE 65 MINUS ONE MONTH PRIOR TO DECEMBER 19, 2015

Beginning (1), we are not reducing (2) benefit because of (3) payments. We do not reduce benefits for months when the disabled worker is age (4) or over.

Fill-in values:

 

Fill-in (1)

Amount of Offset End Date (AMOF-STOP-REL) plus 1 month

Fill-in (2)

 

Choice 1

NH-NAME (possessive)

Choice 2

your

Choice 3

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

Fill-in (3)

 

Choice 1

workers' compensation

Choice 2

public disability

Choice 3

workers' compensation and public disability

Fill-in (4)

65

WCP020 – USED WITH WCP003

The pamphlet explains how we reduce (1) Social Security Disability benefits if the money which (2) and (3) family would receive from Social Security and (4) adds up to more than 80 percent of (5) monthly average earnings. We found that 80 percent of (6) average current earnings is (7).

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

Choice 2

she

Choice 3

you

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

 

Choice 1

workers' compensation

Choice 2

public disability

Choice 3

workers' compensation and public disability

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (6)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (7)

80 Percent Average Current Earnings (ACE-80) in format $$$$$.¢¢

WCP021 – NUMBER HOLDER NEEDS PROOF FOR EXPENSES

If (1) had any expenses related to (2) claim for (3) payments, please give us proof that (4) paid these expenses. These expenses may include medical, legal, or other related expenses. We may be able to deduct some of these expenses when we figure (5) 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

your

Choice 2

his

Choice 3

her

Fill-in (3)

 

Choice 1

workers' compensation

Choice 2

workers' compensation and public disability benefit

Choice 3

public disability benefit

Fill-in (4)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (5)

 

Choice 1

your and your family’s

Choice 2

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

Choice 3

your family’s

Choice 4

your

Choice 5

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) plus “and his family’s”

Choice 6

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) plus “and her family’s

Choice 7

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

WCP022 – CHANGE IN AVERAGE CURRENT EARNINGS (ACE) AMOUNT

We told (1) earlier that we might change the amount of (2) benefits when we got more facts about the money (3) earned while (4) (5) working. Using the new facts about (6) earnings, we found that 80 percent of (7) average current earnings was (8).

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

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (5)

 

Choice 1

was

Choice 2

were

Fill-in (6)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (7)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (8)

80 Percent Average Current Earnings (ACE-80) in format $$$$$.¢¢

WCP023 – NUMBER HOLDER BENEFITS SUSPENDED FOR WORKERS’ COMPENSATION OFFSET - NO LUMP SUM INVOLVED

We have to take into account (1) (2) of (3) when we figure (4) Social Security benefits. Because of (5), (6) monthly Social Security benefits are not payable (7).

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

workers' compensation payment

Choice 2

public disability payment

Choice 3

workers' compensation and public disability payments

Fill-in (3)

 

Choice 1

Workers’ Compensation Payment Amounts (WCPD-WC-AMT) in format $$$$$.¢¢

Choice 2

Public Disability Benefits Amount (WCPD-PDB-AMT) in format $$$$$.¢¢

Choice 3

Sum of the Workers’ Compensation Payment Amounts (WCPD-WC-AMT) and Public Disability Benefits Amount (WCPD-PDB-AMT) in format $$$$$.¢¢

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

this payment

Choice 2

these payments

Fill-in (6)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (7)

 

Choice 1

for this period

Choice 2

Null

WCP024 – NUMBER HOLDER'S MONTHLY BENEFIT AMOUNT (MBA) REDUCED DUE TO WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB)

We have to take into account (1) (2) of (3) when we figure (4) Social Security benefits. Because of (5), we changed (6) monthly Social Security benefits to (7) beginning (8).

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

workers' compensation payment

Choice 2

public disability payment

Choice 3

workers' compensation and public disability payments

Fill-in (3)

 

Choice 1

Workers’ Compensation Payment Amounts (WCPD-WC-AMT) in format $$$$$.¢¢

Choice 2

Public Disability Benefits Amount (WCPD-PDB-AMT) in format $$$$$.¢¢

Choice 3

Sum of the Workers’ Compensation Payment Amounts (WCPD-WC-AMT) and Public Disability Benefits Amount (WCPD-PDB-AMT) in format $$$$$.¢¢

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

this payment

Choice 2

these payments

Fill-in (6)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (7)

 

Choice 1

Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of the MBA change in the format $$$$$.¢¢

Choice 2

NA-HIST-POST-MBA in the format $$$$$.¢¢

Fill-in (8)

 

Choice 1

Effective Date (EFD) on the post-MBR associated with the Monthly Benefit Amount (MBA) change in the format Month CCYY

Choice 2

NA-HIST-START month in the format Month CCYY

WCP025 – AUXILIARY MONTHLY BENEFIT AMOUNT (MBA) CHANGED DUE TO WCPDB AND ENTITLED AUXILIARY

We changed (1) monthly benefit to (2) beginning (3) because we started paying another person on this record. When we figured (4) benefit, we had to take into account (5) (6) payments.

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

Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of the MBA change in the format $$$$$.¢¢

Choice 2

NA-HIST-POST-MBA in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

Effective Date (EFD) on the post-MBR associated with the Monthly Benefit Amount (MBA) change

Choice 2

NA-HIST-START month in the format Month CCYY

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

NH-NAME (possessive)

Fill-in (6)

 

Choice 1

workers' compensation

Choice 2

public disability

Choice 3

workers' compensation and public disability

WCP026 – AUXILIARY MONTHLY BENEFIT AMOUNT (MBA) CHANGED DUE TO WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB) AND TERMINATED AUXILIARY

We changed (1) monthly benefit to (2) beginning (3) because benefits to another entitled person stopped. When we figured (4) benefit, we had to take into account (5) (6) payments.

WCP027 – NUMBER HOLDER HAS EXCLUDABLE AMOUNTS FOR EXPENSES

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-in values:

 

Fill-in (1)

 

Choice 1

NH-NAME (possessive)

Choice 2

NH-NAME (possessive) plus “and his family's”

Choice 3

NH-NAME (possessive) plus “and her family's”

Choice 4

NH-NAME (possessive) plus “family's”

Choice 5

your

Choice 6

your and your family's

Choice 7

your family's

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

workers' compensation

Choice 2

public disability

Choice 3

workers' compensation and public disability

Fill-in (4)

Total amount of excludable expenses

Fill-in (5)

 

Choice 1

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

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) plus “and his family's”

Choice 3

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) plus “and her family's”

Choice 4

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) plus “family's”

Choice 5

your

Choice 6

your and your family's

Choice 7

your family's

WCP028 – USED WITH WCP003 ONE BENEFICIARY’S MONTHLY BENEFIT AMOUNT (MBA) IS OFFSET- NUMBER HOLDER AGE 65 MINUS ONE MONTH PRIOR TO DECEMBER 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-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

your and your family’s

Choice 3

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

Choice 4

your family’s

Choice 5

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) plus “and his family’s”

Choice 6

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) plus “and her family's”

Choice 7

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

Fill-in (2)

 

Choice 1

you reach

Choice 2

he reaches

Choice 3

she reaches

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (4)

 

Choice 1

workers' compensation

Choice 2

workers' compensation and public disability benefit

Choice 3

public disability benefit

Fill-in (5)

 

Choice 1

Workers' compensation

Choice 2

Workers' compensation and public disability benefit

Choice 3

Public disability benefit

Fill-in (6)

 

Choice 1

You

Choice 2

He

Choice 3

She

Fill-in (7)

 

Choice 1

you reach

Choice 2

she reaches

Choice 3

he reaches

WCP029 – NUMBER HOLDER'S WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB) CLAIM PENDING

If (1) workers' compensation and/or public disability benefit payments, we may have to reduce (2) Social Security benefits.

At that time, (3) may also have to pay back any Social Security benefits that (4) not due. Please let us know the decision on the claim right away.

Fill-in values:

 

Fill-in (1)

 

Choice 1

NH-NAME receives

Choice 2

you receive

Fill-in (2)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

you were

Choice 2

he was

Choice 3

she was

WCP030 – NUMBER HOLDER BENEFITS SUSPENDED FOR WORKERS’ COMPENSATION OFFSET (WCOFFS) LUMP SUM INVOLVED

We consider (1) (2) of (3) when we figure (4) Social Security benefits. Because of (5), we cannot pay (6) Social Security benefits (7).

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

workers’ compensation lump-sum payment

Choice 2

public disability benefit lump-sum payment

Choice 3

workers’ compensation and public disability benefit lump-sum payments

Fill-in (3)

 

Choice 1

Show the Lump Sum Gross Amount (INIL-LS-GROSS) amount in the format 99,999.99

Choice 2

Show the total of all Lump Sum Gross Amount (INIL-LS-GROSS) amounts in the format 99,999.99

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (5)

 

Choice 1

this lump-sum payment

Choice 2

these lump-sum payments

Fill-in (6)

 

Choice 1

you

Choice 2

him

Choice 3

her

Fill-in (7)

 

Choice 1

Null

Choice 2

for plus Month CCYY through plus Month CCYY

Choice 3

for plus Month CCYY

WCP031 – NUMBER HOLDER MONTHLY BENEFIT AMOUNT (MBA) REDUCED LUMP SUM AWARD PAYMENT INVOLVED

We consider (1) (2) of (3) when we figure (4) Social Security benefits. Because of (5), we changed (6) monthly Social Security benefits to (7) starting (8).

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

workers’ compensation lump-sum payment

Choice 2

public disability benefit lump-sum payment

Choice 3

workers’ compensation and public disability benefit lump-sum payments

Fill-in (3)

 

Choice 1

Show the Lump Sum Gross Amount (INIL-LS-GROSS) amount in the format 99,999.99

Choice 2

Show the total of all Lump Sum Gross Amount (INIL-LS-GROSS) amounts in the format 99,999.99

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (5)

 

Choice 1

this lump-sum payment

Choice 2

these lump-sum payments

Fill-in (6)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (7)

 

Choice 1

Show the post Master Beneficiary Record (MBR) Monthly Benefit Amount (MBA) associated with the ongoing History Effective Date (EFD) of the MBA change in the format 99,999.99

Choice 2

Show the NA-HIST-POST-MBA occurrence associated with the embedded History Effective Date (EFD) in the format 99,999.99

Fill-in (8)

 

Choice 1

Show the History Effective Date (EFD) on the post Master Beneficiary Record (MBR) associated with the MBA change in the format Month CCYY

Choice 2

Show the NA-HIST-START month in the format Month CCYY

WCP032 – USED WITH WCP003 - INFORMATIONAL REPORTING

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-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

you receive

Choice 2

he receives

Choice 3

she receives

Fill-in (3)

 

Choice 1

you receive

Choice 2

he receives

Choice 3

she receives

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

WCP033 – NUMBER HOLDER'S WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB) STOPS < CURRENT OPERATING MONTH (COM) AND < (AGE 65 PRIOR TO DECEMBER 19, 2015 OR < FRA IF ON OR AFTER DECEMBER 19, 2015)

We do not reduce monthly Social Security benefits once (1) (2) payments stop. We changed (3) monthly benefit to the full rate of (4) beginning (5).

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

workers' compensation

Choice 2

public disability

Choice 3

workers' compensation and public disability

Choice 4

periodic

Fill-in (3)

 

Choice 1

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

Choice 2

your

Fill-in (4)

 

Choice 1

Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of the MBA change in the format $$$$$.¢¢

Choice 2

NA-HIST-POST-MBA in the format $$$$$.¢¢

Fill-in (5)

 

Choice 1

Effective Date (EFD) on the post-MBR associated with the MBA change in the format Month CCYY

Choice 2

NA-HIST-START month in the format Month CCYY

WCP034 – EMBEDDED WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB) PERIOD MONTHLY BENEFIT AMOUNT (MBA) CHANGE AND EFDS

(1) monthly benefit is (2) (3) (4) (5) (6).

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)

Monthly Benefit Amount (MBA) associated with the first Effective Date (EFD) of MBA change

Fill-in (3)

for

Fill-in (4)

First Effective Date (EFD) associated with the Monthly Benefit Amount (MBA) change

Fill-in (5)

 

Choice 1

and

Choice 2

through

Choice 3

Null

Fill-in (6)

 

Choice 1

Null

Choice 2

Last Effective Date (EFD) associated with this Monthly Benefit Amount (MBA) change

WCP035 – LUMP SUM AWARD PAYMENT - METHOD A USED

(1) (2) received a lump-sum award(s) 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 figure 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.

Fill-in values:

 

Fill-in (1)

 

Choice 1

NH-NAME

Choice 2

You

Fill-in (2)

 

Choice 1

has

Choice 2

have

Fill-in (3)

Using all changed occurrence of Injury/Illness (INIL) Data, show the sum of Lump Sum Gross Total (INIL-LS-GROSS) amounts

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

workers' compensation

Choice 2

public disability

Choice 3

workers' compensation and public disability

Fill-in (6)

 

Choice 1

NH-NAME (possessive)

Choice 2

NH-NAME (possessive) plus “and his family's”

Choice 3

NH-NAME (possessive) plus “and her family's”

Choice 4

NH-NAME (possessive) plus “family's”

Choice 5

your

Choice 6

your and your family's

Choice 7

your family's

Fill-in (7)

 

Choice 1

NH-NAME

Choice 2

you

Fill-in (8)

Sum of IDET Weekly Rate Method A (IDET-WK-RATE-A) amounts that correspond to the changed occurrence(s) of Lump Sum Gross Total (INIL-LS-GROSS) in the format $$$$$.¢¢

Fill-in (9)

Sum of Lump Sum Attorney Expenses (INIL-LS-ATY-EX) amounts that correspond to the changed occurrence(s) of Lump Sum Gross Total (INIL-LS-GROSS) in the format $$$$$.¢¢

Fill-in (10)

Sum of Lump Sum Medical Expenses (INIL-LS-MED-EX) amounts that correspond to the changed occurrence(s) of Lump Sum Gross Total (INIL-LS-GROSS) in the format $$$$$.¢¢

WCP036 – LUMP SUM AWARD PAYMENT - METHOD B USED

(1) (2) received a lump-sum award(s) 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 expenses. For this reason, we lowered the weekly rate from (10) to (11).

Fill-in values:

 

Fill-in (1)

 

Choice 1

NH-NAME

Choice 2

You

Fill-in (2)

 

Choice 1

has

Choice 2

have

Fill-in (3)

Using all changed occurrence of Injury/Illness (INIL) Data, show the sum of Lump Sum Gross Total (INIL-LS-GROSS) amounts

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

workers' compensation

Choice 2

public disability

Choice 3

workers' compensation and public disability

Fill-in (6)

 

Choice 1

NH-NAME (possessive)

Choice 2

NH-NAME (possessive) plus “and his family's”

Choice 3

NH-NAME (possessive) plus “and her family's”

Choice 4

NH-NAME (possessive) plus “family's”

Choice 5

your

Choice 6

your and your family's

Choice 7

your family's

Fill-in (7)

 

Choice 1

NH-NAME

Choice 2

you

Fill-in (8)

Sum of Lump Sum Proration Amount (INIL-LS-PROAMT) amounts that correspond to the changed occurrence(s) of Injury/Illness (INIL) data in the format $$$$$.¢¢

Fill-in (9)

Sum of Lump Sum Attorney Expenses (INIL-LS-ATY-EX), Lump Sum Medical Expenses (INIL-MED-EX), Lump Sum Special Expenses (INIL-LS-SPECEX), and Lump Sum-Related Expenses (INIL-LS-RLTDEX) amounts that correspond to the changed occurrence(s) of Lump Sum Gross Total (INIL-LS-GROSS) in the format $$$$$.¢¢

Fill-in (10)

Sum of Lump Sum Proration Amounts (INIL-LS-PROAMT) that correspond to the changed occurrence(s) of Injury/Illness (INIL) data in the format $$$$$.¢¢

Fill-in (11)

Sum of IDET Weekly Rate Method B (IDET-WK-RATE-B) amounts that correspond to the changed occurrence(s) of Lump Sum Gross Total (INIL-LS-GROSS) in the format $$$$$.¢¢

WCP037 – LUMP SUM AWARD PAYMENT - METHOD C USED – USED FOR NUMBER HOLDER ONLY

(1) (2) received a lump-sum award(s) 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 expenses, 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-in values:

 

Fill-in (1)

 

Choice 1

NH-NAME

Choice 2

You

Fill-in (2)

 

Choice 1

has

Choice 2

have

Fill-in (3)

Using all changed occurrence of Injury/Illness (INIL) data, show the sum of Lump Sum Gross Total (INIL-LS-GROSS) amounts

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

workers' compensation

Choice 2

public disability

Choice 3

 

Fill-in (6)

 

Choice 1

NH-NAME (possessive)

Choice 2

NH-NAME (possessive) plus “and his family's”

Choice 3

NH-NAME (possessive) plus “and her family's”

Choice 4

NH-NAME (possessive) plus “family's”

Choice 5

your

Choice 6

your and your family's

Choice 7

your family's

Fill-in (7)

Sum of Lump Sum Attorney Expenses (INIL-LS-ATY-EX), Lump Sum Medical Expenses (INIL-MED-EX), Lump Sum Special Expenses (INIL-LS-SPECEX), and Lump Sum-Related Expenses (INIL-LS-RLTDEX) amounts that correspond to the changed occurrence(s) of Lump Sum Gross Total (INIL-LS-GROSS) in the format $$$$$.¢¢

Fill-in (8)

Using all changed occurrence(s) of Injury/Illness (INIL) data, show the sum of Lump Sum Gross Total (INIL-LS-GROSS) amounts minus the total expenses that are shown in Fill-in (7) in the format $$$$$.¢¢

Fill-in (9)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (10)

Sum of IDET Weekly Rate Method C (IDET-WK-RATE-C) amounts that corresponds to the changed occurrence(s) of Lump Sum Gross Total (INIL- LS-GROSS) in the format $$$$$.¢¢

Fill-in (11)

Changed occurrence of IDET Lump Sum Proration Stop Date Method C (IDET-STOP-C) plus one month that corresponds to the changed occurrence(s) of Lump Sum Gross Total (INIL-LS-GROSS) in the format Month CCYY

WCP038 – NUMBER HOLDER RECEIVES PERIODIC PAYMENTS NO PROOF

We may have to change the amount of (1) benefits when we receive proof of the amount of (2) (3) payments.

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

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

workers' compensation

Choice 2

public disability

Choice 3

workers' compensation and public disability

WCP039 – AUXILIARY BENEFITS SUSPENDED - WCOFFS DUE TO NUMBER HOLDER'S WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB)

We have to take into account (1) (2) when we figure (3) Social Security benefits. Because of (4), (5) monthly Social Security benefits are not payable (6).

Fill-in values:

 

Fill-in (1)

NH-NAME (possessive)

Fill-in (2)

 

Choice 1

workers' compensation payment

Choice 2

public disability payment

Choice 3

workers' compensation and public disability payments

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

 

Choice 1

this payment

Choice 2

these payments

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (6)

 

Choice 1

for this period

Choice 2

Null

WCP040 – AUXILIARY MONTHLY BENEFIT AMOUNT (MBA) CHANGED DUE TO NUMBER HOLDER'S WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB)

We have to take into account (1) (2) when we figure (3) Social Security benefits. Because of (4), we changed (5) monthly Social Security benefit to (6) beginning (7).

Fill-in values:

 

Fill-in (1)

NH-NAME (possessive)

Fill-in (2)

 

Choice 1

workers' compensation payment

Choice 2

public disability payment

Choice 3

workers' compensation and public disability payments

Fill-in (3)

 

Choice 1

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

Choice 2

your

Fill-in (4)

 

Choice 1

this payment

Choice 2

these payments

Fill-in (5)

 

Choice 1

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

Choice 2

your

Fill-in (6)

 

Choice 1

Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of the MBA change in the format $$$$$.¢¢

Choice 2

NA-HIST-POST-MBA in the format $$$$$.¢¢

Fill-in (7)

 

Choice 1

EFD on the post-MBR associated with the MBA change in the format Month CCYY

Choice 2

NA-HIST-START month in the format Month CCYY

WCP041 – MONTHLY BENEFIT AMOUNT (MBA) CHANGE DUE TO WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB) AND COST-OF-LIVING ADJUSTMENT (COLA) NOT PIC A

We have to take into account (1) (2) when we figure (3) Social Security benefits. Because of (4), we changed (5) monthly Social Security benefit to (6) beginning (7). This change also includes the cost of living increase.

Fill-in values:

 

Fill-in (1)

NH-NAME (possessive)

Fill-in (2)

 

Choice 1

workers' compensation payment

Choice 2

public disability payment

Choice 3

workers' compensation and public disability payments

Fill-in (3)

 

Choice 1

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

Choice 2

your

Fill-in (4)

 

Choice 1

this payment

Choice 2

these payments

Fill-in (5)

 

Choice 1

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

Choice 2

your

Fill-in (6)

 

Choice 1

Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of the MBA change in the format $$$$$.¢¢

Choice 2

NA-HIST-POST-MBA in the format $$$$$.¢¢

WCP042 – NUMBER HOLDER MONTHLY BENEFIT AMOUNT (MBA) CHANGE DUE TO WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB) AND COST-OF-LIVING ADJUSTMENT (COLA) NO LUMP SUM INVOLVED

We have to take into account (1) (2) of (3) when we figure (4) Social Security benefits. Because of (5), we changed (6) monthly Social Security benefit to (7) beginning (8). This change also includes the cost of living increase.

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

workers' compensation payment

Choice 2

public disability payment

Choice 3

workers' compensation and public disability payments

Fill-in (3)

 

Choice 1

Workers’ Compensation Payment Amounts (WCPD-WC-AMT) in the format $$$$$.¢¢

Choice 2

Public Disability Benefits Amount (WCPD-PDB-AMT) in the format $$$$$.¢¢

Choice 3

Sum of the Workers’ Compensation Payment Amounts (WCPD-WC-AMT) and the Public Disability Benefits Amount (WCPD-PDB-AMT) and show this total as the value in the format $$$$$.¢¢

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

this payment

Choice 2

these payments

Fill-in (6)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (7)

 

Choice 1

Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of the MBA change in the format $$$$$.¢¢

Choice 2

NA-HIST-POST-MBA in the format $$$$$.¢¢

Fill-in (8)

 

Choice 1

Effective Date (EFD) on the post-MBR associated with the Monthly Benefit Amount (MBA) change in the format Month CCYY

Choice 2

NA-HIST-START month in the format Month CCYY

WCP043 – NUMBER HOLDER MONTHLY BENEFIT AMOUNT (MBA) CHANGE DUE TO WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB) AND COST-OF-LIVING ADJUSTMENT (COLA) LUMP SUM INVOLVED

We have to take into account (1) lump-sum payment(s) of (2) when we figure (3) Social Security benefits. Because of (4), we changed (5) monthly Social Security benefit to (6) beginning (7). This change also includes the cost of living increase.

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

Lump Sum Gross Total (INIL-LS-GROSS) amount in the format $$$$$.¢¢

Choice 2

Total of all Lump Sum Gross Total (INIL-LS-GROSS) amounts in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

 

Choice 1

this payment

Choice 2

these payments

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (6)

 

Choice 1

Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of the MBA change in the format $$$$$.¢¢

Choice 2

NA-HIST-POST-MBA in the format $$$$$.¢¢

Fill-in (7)

 

Choice 1

Effective Date (EFD) on the post-MBR associated with the Monthly Benefit Amount (MBA) change in the format Month CCYY

Choice 2

NA-HIST-START month in the format Month CCYY

WCP044 – AUXILIARY MONTHLY BENEFIT AMOUNT (MBA) CHANGE FOR WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB), COST-OF-LIVING ADJUSTMENT (COLA) AND BENEFICIARY TERMINATED

We changed (1) monthly benefit to (2) beginning (3) because benefits to another entitled person(s) stopped. When we figured (4) benefit, we had to take into account (5) (6) payments. This change also includes the cost-of-living increase.

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

Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of the MBA change in the format $$$$$.¢¢

Choice 2

NA-HIST-POST-MBA in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

Effective Date (EFD) on the post-MBR associated with the Monthly Benefit Amount (MBA) change in the format Month CCYY

Choice 2

NA-HIST-START month in the format Month CCYY

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

NH-NAME (possessive)

Fill-in (6)

 

Choice 1

workers' compensation

Choice 2

public disability

Choice 3

workers' compensation and public disability

WCP045 – AUXILIARY MONTHLY BENEFIT AMOUNT (MBA) CHANGE FOR NUMBER HOLDER’S WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB), COST-OF-LIVING ADJUSTMENT (COLA) AND ANOTHER BENEFICIARY STARTS RECEIVING BENEFITS

We changed (1) monthly benefit to (2) beginning (3) because we started paying another person(s) on this record. When we figured (4) benefit, we had to take into account (5) (6) payments. This change also includes the cost-of-living increase.

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

Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of the MBA change in the format $$$$$.¢¢

Choice 2

NA-HIST-POST-MBA in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

Effective Date (EFD) on the post-MBR associated with the Monthly Benefit Amount (MBA) change in the format Month CCYY

Choice 2

NA-HIST-START month in the format Month CCYY

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

NH-NAME (possessive)

Fill-in (6)

 

Choice 1

workers' compensation

Choice 2

public disability

Choice 3

workers' compensation and public disability

WCP046 – AUXILIARY NOTICE – NUMBER HOLDER'S WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB) STOP – MONTHLY BENEFIT AMOUNT (MBA) NOT AFFECTED

We changed (1) monthly benefit to (2) beginning (3) because (4) present (5) payment(s) do not affect (6) monthly Social Security benefits.

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)

Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of the MBA change in the format $$$$$.¢¢

Fill-in (3)

Effective Date (EFD) on the post-MBR associated with the Monthly Benefit Amount (MBA) change in the format Month CCYY

Fill-in (4)

NH-NAME (possessive)

Fill-in (5)

 

Choice 1

workers' compensation

Choice 2

public disability

Choice 3

workers' compensation and public disability

Fill-in (6)

 

Choice 1

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

Choice 2

your

WCP047 – NUMBER HOLDER MONTHLY BENEFIT AMOUNT (MBA) CHANGE AMOF DELETED FROM POST-MBR

We changed (1) monthly Social Security benefit to (2) beginning (3) because (4) benefits are not affected by (5) receipt of workers' compensation and/or public disability payments.

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

Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of the MBA change in the format $$$$$.¢¢

Choice 2

NA-HIST-POST-MBA in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

Effective Date (EFD) on the post-MBR associated with the Monthly Benefit Amount (MBA) change in the format Month CCYY

Choice 2

NA-HIST-START month in the format Month CCYY

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

WCP060 - WORKER’S COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB) STOPS- NUMBER HOLDER AGE 65 MINUS ONE MONTH AFTER DECEMBER 19, 2015

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-in values:

 

Fill-in (1)

Date of FRA attainment in Month CCYY format

Fill-in (2)

 

Choice 1

NH-NAME (possessive)

Choice 2

your

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (4)

 

Choice 1

worker’s compensation

Choice 2

public disability benefit

Choice 3

worker’s compensation and public disability benefit

Fill-in (5)

 

Choice 1

you reach

Choice 2

he reaches

Choice 3

she reaches

WCP061 - BENEFICIARY’S MONTHLY BENEFIT AMOUNT (MBA) IS OFFSET- NUMBER HOLDER AGE 65 MINUS ONE MONTH AFTER DECEMBER 19, 2015

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-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

NULL plus BGN plus BLN (possessive)

Choice 3

your and your family’s

Choice 4

your family’s

Choice 5

null plus BGN plus BLN (possessive) plus and his family’s

Choice 6

NULL plus BGN plus BLN (possessive) plus and her family’s

Choice 7

NULL plus BGN plus BLN (possessive) plus family’s

Fill-in (2)

 

Choice 1

you reach

Choice 2

he reaches

Choice 3

she reaches

Fill-in (3)

Date of FRA attainment in the format Month CCYY

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (5)

 

Choice 1

worker’s compensation

Choice 2

public disability benefit

Choice 3

worker’s compensation and public disability benefit

Fill-in (6)

 

Choice 1

Your

Choice 2

His

Choice 3

Her

Fill-in (7)

 

Choice 1

worker’s compensation

Choice 2

public disability benefit

Choice 3

worker’s compensation and public disability benefit

Fill-in (8)

 

Choice 1

You

Choice 2

He

Choice 3

She

Fill-in (9)

 

Choice 1

you decide

Choice 2

he decides

Choice 3

she decides

Fill-in (10)

 

Choice 1

you reach

Choice 2

he reaches

Choice 3

she reaches

C. WDS Universal Text Identifiers – Work And Earnings Deduction/Suspension

WDS009 – THIS UTI EXPLAINS TO THE BENEFICIARY THAT THE FOLLOWING YEAR WHEN HIS OR HER EARNINGS ARE KNOWN THE BENEFICIARY'S BENEFITS WILL BE REEVALUATED

After the year has ended and we know (1) actual earnings, we will review (2) record. We will compare the actual and estimated earnings to decide if we paid (3) more or less than (4) due. We will then pay any benefits due, or we will ask (5) to pay us back if we paid too much.

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 1

her

Fill-in (3)

 

Choice 1

you

Choice 2

him

Choice 1

her

Fill-in (4)

 

Choice 1

you were

Choice 2

he was

Choice 3

she was

Fill-in (5)

 

Choice 1

you

Choice 2

him

Choice 3

her

WDS010 – REFER TO WORKSHEET HEADER NL 00730.149D

WDS012 – REFER TO WORKSHEET HEADER NL 00730.149D

WDS014 – REFER TO WORKSHEET HEADER NL 00730.149D

D. WDW Universal Text Identifiers - Withdrawal

WDWC02 – CAPTION

(1) Withdrawal Can Be Cancelled

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

WDW002 – REQUEST TO WITHDRAWAL CLAIM

We have approved (1) request to withdraw (2) claim for all Social Security benefits. This cancels our earlier decisions on (3) claim. (4) may withdraw a retirement claim only once in (5) lifetime.

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

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

Fill-in (4)

 

Choice 1

You

Choice 2

He

Choice 3

She

Fill-in (5)

 

Choice 1

your

Choice 2

his

Choice 3

her

WDW006 – CLAIM 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 from the date you receive 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.

E. WEP Universal Text Identifiers – Windfall Elimination Provision

WEP003 – WINDFALL ELIMINATION PROVISION APPLIED FOR THE FIRST TIME

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-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)

Date in the format Month CCYY

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

you receive

Choice 2

he receives

Choice 3

she receives

Fill-in (5)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (6)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (7)

 

Choice 1

Your

Choice 2

His

Choice 3

Her

Fill-in (8)

 

Choice 1

you were

Choice 2

he was

Choice 3

she was

Fill-in (9)

www.socialsecurity.gov/pubs/EN-05-10045.pdf

WEP004 – WINDFALL ELIMINATION PROVISION REMOVED

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-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

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

Fill-in (2)

Date of Windfall Elimination Provision (WEP) stop in format Month CCYY

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (4)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (5)

www.socialsecurity.gov/pubs/EN-05-10045.pdf

F. WFO Universal Text Identifier – Windfall Offset

We may have to reduce these benefits if (1) received Supplemental Security Income (SSI) for this period. When we decide whether or not we will have to reduce (2) Social Security benefits, we will send (3) another letter. We will pay (4) any Social Security benefits (5) due for this period.

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

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (4)

 

Choice 1

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

Choice 2

you

Fill-in (5)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900730146
NL 00730.146 - W Paragraphs and Captions - 08/01/2017
Batch run: 08/01/2017
Rev:08/01/2017