Identification Number:
NL 00725 TN 25
Intended Audience:See Transmittal Sheet
Originating Office:Systems OITEBS
Title:Modernized Claims System (MCS) Notices
Type:POMS Transmittals
Program:Title II (RSI); Title XVI (SSI); Disability; Medicare
Link To Reference:
 
PROGRAM OPERATIONS MANUAL SYSTEM
Part 09 - Notices, Letters and Paragraphs
Chapter 007 - Letters and Paragraphs for Title II, Title XVI, and Title XVIII
Subchapter 25 - Modernized Claims System (MCS) Notices
Transmittal No. 25, 06/2018

Audience

FO/TSC: CS, CS TII, DRT, DT, FR, OA, OS, RR, CSR, TA, TSC-CSR
PSC: BA, CA, CCRE, CS, TSA, TST, DS, ICDS, IES, ILPDS, IPDS, ISRA, NPR, PETE, RECONR, SCPS
OCO-ODO: BTE, CCE, CR, CST, CT, CTE, CTE TE, DE, DEC, DS, DSE, PAS, PETE, PETL, RCOVTA, RECOVR
OCO-OEIO: BET, BIES, BTE, CC, CCRE, CDT, CR, CTE, ERE, FDE, PETL, RECONE, RECONR, RECOVR

Originating Component

OITEBS

Effective Date

Upon Receipt

    Background

    We are updating Program Operations Manual System (POMS) sections in NL 00725 effective with Modernized Claims System (MCS) March 30, 2018 release.

    Language changes for notices in the attached sections are a direct result of updates requested by the Office of Income Security Programs (OISP) and the Centers for Medicare & Medicaid Services (CMS) in support of the Social Security Number Removal Initiative (SSNRI). This initiative involved replacing the Social Security Number (SSN) based claim number displayed on the Medicare card with the new Medicare Beneficiary Identification (MBI) number.

    NL 00725.130 “ATY” UTIs - Attorney Fee

    We corrected several spacing, grammatical and punctuation errors for UTIs ATYR01, ATY004, ATYR06, ATY808 and ATY834.
    We removed mention of SSI from the title of the UTI ATY836 as it only pertains to the withholding of past due representative fees from the claimant’s benefits.

    NL 00725.135 “BEN” UTIs – Benefit Information

    We updated fill-in 5 for UTI BEN030 to show what information should be coded for this selection and corrected spacing between listing the fill-in choices for fill-in 2.
    We corrected several spacing, grammatical and punctuation errors for UTIs BEN032 and BEN051.
    We updated the language in the UTIs BEN051 and BEN052 to specify the type of claim number by adding “Social Security” in front of “claim number”. We also updated formatting within the subchapter.

    NL 00725.225 “ENT” UTIs - Entitlements

    We corrected several spacing, grammatical and punctuation errors for UTIs ENTR02, ENT029, ENT040, and ENT043.
    We updated language and fill-ins in the UTIs ENT027 and ENT028 to remove references to a specific Social Security Number (SSN).

    NL 00725.265 “HIB” UTIs – Health Insurance Benefits

    We corrected several spacing, grammatical and punctuation errors throughout the language and fill-ins for UTIs HIB001, HIB003, HIB004, HIB011, HIB038, HIB042, HIB044, HIBR60, HIB062, HIB068, HIB072, HIB074, HIB095, HIB096, HIB128, HIB129, HIB151, HIB152, HIB157 and HIB215.

    We updated the following:

    · UTI HIB002 to remove language advising beneficiaries that the initial award notice serves as proof of coverage. Use of the initial award notice as proof of coverage is no longer valid because the initial award notice will no longer contain the MBI number;
    · UTI HIB005 to correct the language that explains the amount to be shown in fill-in 5 and the month and date format for fill-in 3;
    · UTI HIB013 to correct the language to replace the word “penalty” with the words “premium surcharge”; and
    · UTI HIB015 to correct the fill-in choices for fill-in 1 from three choices to two choices.
    We removed UTI HIB022 due to low usage and availability of current alternative language. This UTI is now obsolete.
    We updated the following:
    · UTI HIBR30 to spell out the acronym “COM” in fill-in 6 to show its meaning as “current operating month”;
    · UTI HIB090, updated the language to remove the words “no longer” and replace them with the word “not”; and
    · UTI HIB096, updated the language to reduce the amount of time claimants wait before contacting the Railroad Retirement Board (RRB) due to non-receipt of their Medicare card. We re-ordered the fill-in choices for uniformity.

    NL 00725.345 “PAY” UTIs - Payment

    We corrected several spacing, grammatical and punctuation errors throughout the language and fill-ins for UTIs for PAY009, PAY024, PAYC27, PAY030, PAY032, PAY033, PAY043, PAY073, PAY090 and Pay161.

    We updated language and fill-ins in the UTI PAY033 to remove references to a specific Social Security number (SSN).

    NL 00725.375 “REF” UTIs - Referral

    We corrected the language showing the website address from “www.ssa.gov” to www.socialsecurity.gov for UTIs REF001, REF003 and REF008.
    We updated the language in the UTI REF002 to advise beneficiaries living abroad to contact SSA or the Federal Benefits Unit (FBU) that services their country. We added a fill-in to accommodate the web address for obtaining a list of FBUs.
    We corrected several spacing, grammatical and punctuation errors throughout the language and fill-ins for UTIs REF011 and REF013.

    NL 00725.470 “WCP” UTIs – Worker’s Compensation

    We updated language and fill-ins in the UTIs WCP001, WCP009, WCP029 and WCP032 to incorporate the “BOLD” text for uniformity.
    We corrected several spacing, grammatical and punctuation errors throughout the language and fill-ins for UTIs WCP005, WCPR06, WCPR07, WCP007, WCPR09, WCP010, WCP012, WCP013, WCPR16, WCP018, WCPR20, WCP021, WCPR24, WCP028, WCP029, WCPR31, WCP032, WCP060 and WCP061.


    NL 00725.130 “ATY” UTIs – Attorney Fee

    ATYC01 Caption

    Information About  (1)  Fees

    Fill-in:

    “Lawyer's”/“Representative's”

    ATYC02 Caption

    How To Ask Us To Review the  (1) 

    Fill-in:

    “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:

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

    lawyer/participant in the demonstration project

    first and last name of number holder/you

    “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:

    attorney fee amount *

    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:

    “your attorney's”/“your representative's”/“the attorney's”/“the representative's”

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

    “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:

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

    “lawyer”/“representative”

    Ms. plus BLN/Mr. plus BLN/BGN/BGN plus BLN/“you”

    “lawyer”/“representative”

    Ms. plus BLN/Mr plus BLN/BGN/BGN plus BLN

    “her”/ “his”/ “your”

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

    “lawyer”/“representative”

    “lawyer”/“representative”

    “lawyer”/“representative”

    “lawyer”/“representative”

    “her”/ “him”/ “you”

    “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:

    “helped”/“may have helped”

    amount withheld

    “your”/“her”/“his”

    “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:

    “representative”

    “representative's”

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

    “the benefits due you and your family”/“your benefits”

    always use “the”

    “representative”

    “representative”

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

    “her”/“his”/“your”

    Month YYYY/Month YYYY and Month YYYY/Month YYYY through Month YYYY

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

    A. proof of

    B. more information about

    “her”/“his”/“your”

    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*

    “her”/“his”/“your”

    “representative”

    “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:

    “your”/name, possessive

    “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:

    FN possessive

    amount

    month and year/month and year through month and year

    person that signs the fee agreement*

    “lawyer”/“representative”

    “lawyer”/“representative”

    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:

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

    “her”/“his”/“your”

    Month YYYY/Month YYYY and Month YYYY/Month YYYY through Month YYYY

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

    A. proof of

    B. more information about

    “her”/“his”/“your”

    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*

    “her”/“his”/“your”

    “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:

    SN

    “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:

    SN

    “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:

    Beneficiary's full name

    SN

    “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:

    SN

    ATY011 Address for Sending Fee Petition

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

    Fill-in:

    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:

    “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:

    money amount

    “your”/name, possessive

    “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:

    “lawyer”/“representative”

    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.*

    “lawyer”/“representative”

    “lawyer”/“representative”

    “lawyer”/“representative”

    “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:

    “representative”

    “representative”

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

    “representative”

    “representative”

    “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:

    “lawyer's”/“representative's”

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

    MM/YYYY or MM/YYYY through MM/YYYY

    “lawyer”/“representative”

    Show amount of the fee in $$$$.¢¢ format.

    “lawyer”/“representative”

    “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:

    Choice 1 - lawyer's

    Choice 2 - representative's

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

    Choice 1 - MM/YYYY

    Choice 2 - MM/YYYY through MM/YYYY

    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. *

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

    Choice 1 – MM/YYYY

    Choice 2 - MM/YYYY through MM/YYYY

    Choice 1 - lawyer

    Choice 2 - representative

    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. *

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

    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 *

    Choice 1 - him

    Choice 2 - her

    Choice 3 - them *

    Choice 1 - lawyer

    Choice 2 - representative

    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:

    legal payment deduction amount

    “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:

    SN possessive

    “lawyer”/“representative”

    SN possessive

    “lawyer”/“representative”

    SN

    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:

    “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:

    attorney name/representative name

    SN

    “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:

    “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:

    beneficiary name

    “your”/“her”/“his”

    “you”/“she”/“he”

    “lawyer”/“representative”

    beneficiary name

    “the”

    “lawyer”/“representative”

    “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:

    “Your”/FN possessive

    money amount

    month and year/month and year through month and year

    “lawyer”/“representative”

    pending fee amount

    “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 Hearings Operations
    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:

    “lawyer”/“representative”

    “lawyer”/“representative”

    “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

    “lawyer”/“representative”

    “null”

    “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 Hearings Operations
    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:

    Beneficiary name

    “lawyer”/“representative”

    “lawyer”/“representative”

    “lawyer”/“representative”

    “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

    “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 Hearings Operations
    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:

    “lawyer”/“representative”

    “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:

    “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:

    “Your”/FN possessive

    money amount

    month and year/month and year through month and year

    “your”/“her”/“his”

    money amount

    month and year/month and year through month and year

    “lawyer”/“representative”

    “you”/SN

    “your”/“her”/“his”

    the total fee amount

    “lawyer”/“representative”

    ATY836 Explanation to the Beneficiary About the Withholding of Representative Fees from Past-Due Benefits

    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:

    money amount

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

    “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:

    money amount

    “your”/name, possessive

    “the”

    money amount

    “your”/“her”/“his”

    “the”

    “you”/name

    “your”/“her”/“his”

    NL 00725.135 “BEN” UTIs – Benefit Information

    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:

    your/beneficiary's given name plus “beneficiary's last name possessive”

    “you”/“she”/“he”

    “your”/“her”/“his”

    “you”/“her”/“him”

    EFD month

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

    MBA amount, corresponding to EFD from fill-in 5

    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:

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

    “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:

    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

    “first”/“next”

    “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 Social Security claim number.

    Fill-ins:

    “BGN plus BLN”/“you”

    “your”/“his”/“her”

    BEN052 Benefits Paid in Separate Check

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

    Fill-in:

    “BGN plus BLN”/“you”

    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:

    “your”/“her”/“his”

    type of benefit

    “you are”/“she is”/“he is”

    “your”/“her”/“his”

    “your”/“her”/“his”

    Money fill-in

    type of benefit

    Money fill-in

    “your”/“her”/“his”

    NL 00725.225 “ENT” UTIs – Entitlement

    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:

    BGN plus BLN plus “was”/You were

    “her”/“his”/“your”

    Month YYYY/Month YYYY and Month YYYY/Month YYYY through Month YYYY

    Ms. plus BLN plus “was”/Mr. plus BLN plus “was”/You were

    “her”/“his”/“your”

    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”

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

    “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:

    BGN plus BLN plus “was”/you were

    Month YYYY/Month YYYY and Month YYYY/Month YYYY through Month YYYY

    Ms. plus BLN plus “was”/Mr. plus BLN plus “was”/you were

    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”

    Month YYYY

    “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:

    “You”/FN

    “is”/“are”

    money amount ($xxx.xx)

    NH's name

    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:

    type of benefit *

    “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:

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

    “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:

    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:

    “You”/FN

    “is”/“are”

    type of benefit

    month and year of entitlement

    “you”/“her”/“him”

    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:

    FN

    “are”/“is”

    type of benefit (e.g., retirement)

    DOEC in format “January 1988”

    “through”/null

    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:

    SN in format “Mr. Jones” or “you”

    Date in format “May 1993”

    “your”/“her”/“his”

    “your”/“her”/“his”

    ENT023 Suspension Months Involved

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

    Fill-ins:

    “you”/SN

    “at this time”/“for”/“beginning”

    first month and year for which being suspended/null

    “and”/“through”/null

    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:

    “you”/FN

    “are”/“is”

    “your/her/him”

    ENTR25 Reduced Benefits

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

    Fill-ins:

    “You”/SN

    “husband's”/“wife's”

    ENT026 Award Introduction

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

    Fill-ins:

    “You”/FN

    “are”/“is”

    type of benefit

    month and year of entitlement or election

    ENTR26 Delayed Claimant

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

    Fill-ins:

    “you”/beneficiary's name

    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 the record of  (6)  beginning  (7) .

    Fill-ins:

    “You are”/“He is”/“She is”

    disability/retirement

    Date fill-in

    “You are”/“He is”/“She is”

    type of benefit

    NH's full name

    Date fill-in

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

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

    Fill-ins:

    “You are”/“He is”/“She is”

    type of benefit

    NH's full name

    Date fill-in

    “you”/“he”/“her”

    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:

    “You are”/“She is”/“He is”

    “your”/“her”/“his”

    Date fill-in

    “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:

    “You”/SN

    month and year

    “and”/“through”/null

    month and year/null

    “beginning”/null

    month and year

    “and”/“through”/null

    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:

    “you”/SN

    month and year

    “and”/“through”/null

    month and year/null

    month and year

    “and”/“through”/null

    month and year/null

    “beginning”/null

    month and year

    “and”/“through”/null

    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:

    “you”/SN

    month and year

    “and”/“through”/null

    month and year/null

    month and year

    “and”/“through”/null

    month and year/null

    month and year

    “and”/“through”/null

    month and year/null

    “beginning”/null

    month and year

    “and”/“through”/null

    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:

    “you”/“her”/“him”

    effective date in format April 1997

    “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:

    “your”/SN possessive

    MBA

    ENT037 Entitlement Introductory Statement

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

    Fill-ins:

    “your”/FN possessive

    type of benefit

    “your”/“her”/“his”

    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:

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

    “spouse's/child's/parent's”

    “your”/“her”/“his”

    DOEC in format “July 1992”

    “you”/“her”/“him”

    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:

    FN in format “Mr. Jack Jones” or “You”

    “are”/“is”

    “widow's”/“widower's”/“child's”/“disabled widow's”/“disabled widower's”/“mother's”/“father's”

    DOEC in format “May 1993”

    “you”/“she”/“he”

    “are”/“is”

    LSAP in format “$999.99”

    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:

    BGN plus BLN plus “is”/You are

    “her”/“his”/“your”

    Month YYYY/Month YYYY and Month YYYY/Month YYYY through Month YYYY

    Month YYYY

    “she”/“he”/“you”

    “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:

    BGN plus BLN plus “was”/“You were”

    “mother's”/“father's”/“spouse's”

    Month YYYY and Month YYYY/Month YYYY through Month YYYY

    Month YYYY

    Ms. plus BLN plus “is”/Mr. plus BLN plus “is”/“you are”

    “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:

    “your”/“her”/“his”

    type of benefit

    “you”/“her”/“him”

    NH-NAME (possessive)

    “you are”/“she is”/“he is”

    NL 00725.265 “HIB” UTIs – Health Insurance Benefits

    HIBC01 Caption

    Information About Medicare

    HIBC05 Caption

    Why  (1)  Cannot Qualify for Medicare

    Fill-in:

    “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:

    “Your”/FN

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

    Date in format June 2013

    “and Part B (medical insurance) starts”

    Date in format June 2013

    HIB002 New Medicare Card – PIC Change Conversion Award

     (1)  will get a Medicare card within 2 weeks.  (2)  show this card when  (3)  medical care. To learn more about what Medicare covers, visit Medicare.gov. If  (4)  questions about  (5)  Medicare coverage, call 1-800-MEDICARE (1-800-633-4227).

    Fill-ins:

    “You”/“BGN plus BLN”

    “You should”/“He should”/“She should”

    “you need”/“he needs”/“she needs”

    “you have”/“he has”/“she has”

    “your”/“his”/“her”

    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:

    “You are”/“She is”/“He is”

    “medical insurance coverage/medical or hospital insurance coverage”

    “your”/“her”/“his”

    “You”/“She”/“He”

    month and year

    month and year

    “You”/“She”/“He”

    “you”/“she”/“he”

    “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:

    “You are”/“She is”/“He is”

    “medical insurance coverage”

    “your”/“her”/“his”

    “You”/“She”/“He”

    month and year

    “you”/“she”/“he”

    HIB005 SMI Premium Billing

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

    Fill-ins:

    “Your”/“His”/“Her”

    Amount of Part B premium in $$$$$.¢¢ format

    Date in MonthCCYY format

    null/“and”/Null

    Show the amount of the Part B premium in the format $$$$$¢¢ plus the word “beginning” plus show the start date that corresponds to the second premium rate returned from the HSA utility in the format MMCCYY

    HIB008 Premium Deductions

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

    Fill-ins:

    “your”/“her”/“his”

    “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:

    “your”/“null”/FN possessive

    “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:

    “your”/“her”/“his”

    “[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

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

    HIB013 Medicare Premium Penalty

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

    Fill-ins:

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

    “you”/“she”/“he”

    “you”/“she”/“he”

    HIB014 State Buy-in

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

    Fill-ins:

    “The State of”/null

    name of jurisdiction making payments

    “your”/“her”/“his”

    “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:

    “your”/“Beneficiary's name (possessive)”

    “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:

    “You”/FN

    “you”/“he”/“she”

    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:

    “you”/“she”/“he”

    “receive”/“receives”

    HIB021 Subsequent Award – Medicare Not Affected

    This letter does not affect  (1)  Medicare benefits.

    Fill-in:

    “your”/“her”/“his”

    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:

    “you”/FN

    Earlier SMI entitlement date *

    Earlier SMI entitlement date *

    Amount of SMI premium from earlier date *

    Earlier SMI entitlement date *

    Month prior to current operating month

    (*) 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:

    “your”/SN possessive

    date buy-in begins in format MMMM d, YYYY

    “your”/SN 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:

    “You”/SN

    “are”/“is”

    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:

    “you”/“she”/“he”

    “receive”/“receives”

    “you”/“her”/“him”

    “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:

    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:

    “You”/“She”/“He”

    “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:

    “You”/“She”/“He”

    ““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:

    “You are”/“She is”/“He is”

    “your”/“her”/“his”

    “You”/“She”/“He”

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

    “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:

    NH Name

    onset date

    date of death - NH

    “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:

    “you receive”/“FN receives”

    “you are”/“she is”/“he is”

    “imprisoned”/“confined in an institution” *

    “your”/“her”/“his”

    “you are”/“she is”/“he is”

    “prison”/“the institution” *

    “You”/“She”/“He”

    “you are”/“she is”/“he is”

    “prison”/“the institution” *

    “you”/“she”/“he”

    “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:

    “You”/FN

    “have”/“has”

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

    “you do”/“he does”/“she does”

    “you are”/“he is”/“she is”

    “you”/“he”/“she”

    “you have”/“he has”/“she has”

    “Your”/“His”/“Her”

    “you”/“he”/“she”

    “you”/“he”/“she”

    “you sign”/“he signs”/“she signs”

    “you want”/“he wants”/“she wants”

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

    “you”/“he”/“she”

    “you sign”/“he signs”/“she signs”

    “your”/“his”/“her”

    “you sign”/“he signs”/“she signs”

    “You”/“He”/“She”

    “you meet”/“he meets”/“she meets”

    “You are”/“He is”/“She is”

    “You have”/“He has”/“She has”

    “you or your”/“he or his”/“she or her”

    “You”/“He”/“She”

    “you”/“he”/“she”

    “You”/“He”/“She”

    “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”

    “your”/“his”/“her”

    “your”/“his”/“her”

    “you need”/“he needs”/“she needs”

    “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:

    “you want/she wants/he wants”

    “you”/“she”/“he”

    “hospital/medical/hospital and medical”

    HI or SMI NONEQRELST

    “you”/“she”/“he”

    “you want/she wants/he wants”

    “hospital/medical/hospital and medical”

    HI or SMI NONEQRELST

    “you”/“she”/“he”

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

    HI or SMI NONEQRELST

    date in format MM/YYYY

    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:

    “you”/FN

    “are”/“is”

    “your”/“her”/“his”

    “you are”/“she is”/“he is”

    “your”/“her”/“his”

    “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:

    “you”/SN

    “you are”/“she is”/“he is”

    “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:

    “you want/she wants/he wants”

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

    “find”/“finds”

    HIB090 Medicare Terminates, Destroy Card

     (1)  Medicare card will not be valid when  (2)   (3)  coverage ends. Please destroy  (4)  card after  (5)  coverage ends.

    Fill-ins:

    null plus FN possessive/“Your”

    “his”/“her”/“your”

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

    “his”/“her”/“your”

    “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:

    “your”/SN possessive/FN possessive

    “retirement”/“disability”

    “your”/“her”/“his”

    “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:

    “your”/SN possessive

    “hospital insurance/medical insurance/hospital and medical insurance”

    “Your”/“Her”/“His”

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

    “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. The RRB will issue  (3)  Medicare card. If  (4)  not receive  (5)  Medicare card in two weeks, you should contact the local office of the Railroad Retirement Board.

    Fill-ins:

    “You are”/“He is”/“She is”

    “your”/“his”/“her”

    “your”/“his”/“her”

    “you do”/“he does”/“she does”

    “your”/“his”/“her”

    HIB103 Third Party Buy-in, Closed Period

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

    Fill-ins:

    The State of/null

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

    “your”/SN possessive

    “hospital/medical/hospital and medical”

    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:

    “your”/SN possessive/FN possessive

    “hospital/medical/hospital and medical”

    date in format “MM/YYYY”

    “You”/“She”/“He”/FN possessive

    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:

    “You”/“beneficiary's given name”/“beneficiary's name”

    “your”/“her”/“his”

    “hospital/medical/hospital and medical”

    “you are”/“she is”/“he is”

    “your”/“her”/“his”

    “you”/“her”/“him”

    “your”/SN possessive

    “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:

    NHFN plus “is”/you are

    “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:

    “You are”/SN plus “is”

    “hospital insurance/medical insurance/hospital and medical insurance”

    “you are”/“he is”/“he is”

    disabled/over age 65

    “your”/“her”/“his”

    “hospital insurance/medical insurance/hospital and medical insurance”

    HIB124 Awards – Previous SMI

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

    Fill-ins:

    “you”/“she”/“he”

    “has”/“have”

    Month CCYY hospital coverage begins

    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:

    “your”/“her”/“his”

    “you”/“she”/“he”

    “your”/“her”/“his”

    “your”/“her”/“his”

    “your”/“her”/“his”

    “your”/“her”/“his”

    “your”/“her”/“his”

    HIB126 ESRD Awards, Beneficiary Previously Receiving Premium HI

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

    Fill-in:

    “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:

    “you”/“she”/“he”

    [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:

    “your”/“her”/“his”

    12th/36th

    “you”/“she”/“he”

    got your transplant/got her transplant/got his transplant/stops dialysis/stop dialysis

    “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:

    “you are”/“she is”/“he is”

    “your”/“her”/“his”

    “you”/“she”/“he”

    “you are”/“she is”/“he is”

    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:

    “you”/“she”/“he”

    “stopped regular dialysis”/“received a kidney transplant”

    date of event in “Month CCYY” format

    “your”/“her”/“his”

    “your”/“her”/“his”

    month Medicare ends in “Month CCYY” format

    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:

    “your”/“her”/“his”

    “your”/“her”/“his”

    “you”/“her”/“him”

    “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:

    “you resume”/“she resumes”/“he resumes”

    “get”/“gets”

    “you”/“she”/“he”

    “your”/“her”/“his”

    HIB151 Closed Period Third Party Buy-in

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

    Fill-ins:

    “You”/“She”/“He”

    date, in format “Month CCYY”

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

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

    (13) Hospital Insurance Start Date (HI-START) 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) 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:

    “you are”/SN plus “is”

    “you”/“she”/“he”

    “your”/“her”/“his”

    “your”/“her”/“his”

    “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:

    “you are”/SN plus “is”

    “you”/“she”/“he”

    “your”/“her”/“his”

    “you live/she lives/he lives”

    “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:

    Show the IRMAA level 1 yearly amount for singles

    Show the IRMAA level 1 yearly amount for couples

    “he has”/“she has”/“you have”

    “her”/“him”/“you”

    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:

    “you are”/“she is”/“he is”

    “your”/“her”/“his”

    “hospital and medical”/“hospital”

    “Your”/“Her”/“His”

    “hospital and medical”/“hospital”

    HI termination date in the format May 1999

    “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) .

    Fill-ins:

    date in format July 2013

    date in format July 2013

    Money amount

    date in format July 2013

    date in format July 2013

    date in format July 2013

    Money amount

    money amount

    NL 00725.345 “PAY” UTIs – Payment

    PAYC01 Caption

    What We Will Pay And When

    PAYC02 Caption

     (1)  Payment of $  (2) 

    Fill-ins:

    “Your”/SN possessive

    Amount of payment

    PAYC03 Caption

     (1)  Regular Monthly Payment

    Fill-in:

    “Your”/SN possessive

    PAYC04 Caption

     (1)  Payment of $  (2) 

    Fill-ins:

    “Your”/SN possessive

    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:

    “your”/Beneficiary's FN possessive

    dictated text *

    “you”/“her”/“him”

    “your”/“her”/“his”

    dictated text *

    “your”/“her”/“his”

    “you”/“her”/“him”

    “you”/“her”/“him”

    “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:

    Amount of first payment

    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:

    null

    “you”/SN/FN/First Name

    “are”/“is”

    month and year

    “and”/“through”/null

    month and year/null

    PAY004 Current or Deferred Benefits Due

    You will receive $  (1)  for  (2)  around  (3) .

    Fill-ins:

    Payment amount

    Month and year payment is due

    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:

    null/“You will receive”

    [1a] for [1b].

    [1a] Money fill-in

    [1b] Date fill-in the format “September 1995”

    Money fill-in

    “on or about the”/“for”/“through”

    “third”/“second Wednesday”/“third Wednesday”/“fourth Wednesday”/Date in the format “July 1994”

    “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:

    “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:

    “Your”/SN possessive/FN possessive/First Name possessive

    “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:

    null

    “this amount”/“these amounts”

    PAY019 Summary Sheet - Introduction

    Here is how we figured  (1)   (2)   (3)  :

    Fill-ins:

    “your”/FN possessive

    “first payment”

    null

    PAY020 Summary Sheet – Benefits Due

    Benefits due for  (1)  . . . . . . . . . . . . . .  (2) 

    Fill-ins:

    month and year

    null/“,”

    PAY022 Summary Sheet – Subtraction Explanation

     (1)  we subtracted because  (2) 

    Fill-ins;

    “Amount”/“Amounts”

    “of:”/“of”

    PAY023 Summary Sheet - Introduction

    Here is how we figured  (1)   (2)  effective  (3)  :

    Fill-ins:

    FN possessive/“your”

    “regular monthly payment”

    Month and year

    PAY024 Summary Sheet – Monthly Benefit Amount

     (1)  entitled to a monthly benefit of  (2)  . . . . . . .  (3) 

    Fill-ins:

    “You are”/“She is”/“He is”

    null/variable length ellipsis

    MBA amount

    PAY025 Summary Sheet – Monthly Payment Amount

    This equals the amount of  (1)   (2)   (3)   (4) 

    Fill-ins:

    SN possessive/“your”

    “first payment”

    variable length ellipsis

    Money amount

    PAY026 Summary Sheet - Introduction

    Here is how we figured  (1)   (2)  benefits:

    Fill-ins:

    FN possessive/“your”

    “current”/“past”

    PAYC27 Caption

    How  (1)  Benefits Can Be Paid

    Fill-in:

    Beneficiary's name (possessive)/Your

    PAY027 Summary Sheet – Subtraction Explanation

     (1)  we must subtract because  (2) .

    Fill-ins:

    “Amount”/“Amounts”

    “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:

    “Your”/“Her”/“His”

    Money fill-in

    “your”/“her”/“his”

    Money fill-in

    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:

    “Your”/“Her”/“His”

    Money fill-in

    Type of benefit

    Money fill-in

    “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  (5)  record.

    Fill-ins:

    “He”/“She”/“You”

    Money fill-in

    Date fill-in

    “he is”/“she is”/“you are”

    “his”/“her”/“your”

    PAY041 Summary Sheet – SMI Arrearage

    Additional amount we subtracted for medical insurance premium due one month in advance  (1) .

    Fill-in:

    Premium amount

    PAY042 Summary Sheet – Benefits Due

    Benefits due for  (1)  . . . .  (2)  . . . .  (3) 

    Fill-ins:

    Month and year

    null or variable length ellipsis

    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:

    null

    “you are”/“she is”/“he is”

    Month and year

    “and”/“through”/null

    Month and year/null

    Month and year

    “and”/“through”/null

    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:

    null

    “you are”/“she is”/“he is”

    Month and year

    “and”/“through”/null

    Month and year/null

    Month and year

    “and”/“through”/null

    Month and year/null

    Month and year

    “and”/“through”/null

    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:

    null

    “you are”/“she is”/“he is”

    Month and year

    “and”/“through”/null

    Month and year/null

    Month and year

    “and”/“through”/null

    Month and year/null

    Month and year

    “and”/“through”/null

    Month and year/null

    Month and year

    “and”/“through”/null

    Month and year/null

    PAY046 Summary Sheet – Work Deductions (Use with PAY022)

     (1)  work  (2)   (3) 

    Fill-ins:

    NH FN possessive/“Your”

    null/variable length ellipsis

    Amount

    PAY047 Summary Sheet – Maritime Tax Subtraction (Use with PAY022)

    unpaid Social Security taxes due for  (1)  maritime taxes. . . .  (2) 

    Fill-ins:

    FN possessive/“your”

    Amount

    PAY048 Summary Sheet – SMI Premium Subtraction (Use with PAY022)

    premiums for medical insurance . . . . . . . . . .  (1) 

    Fill-in:

    Amount of premiums

    PAY049 Summary Sheet - Subtotal

    This equals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  (1) 

    Fill-in:

    Amount

    PAY050 Summary Sheet - Rounding

    rounding [we must round down to a whole dollar] . . . . .  (1) 

    Fill-in:

    Rounding amount

    PAY051 Summary Sheet – Attorney Fee Withholding (Use with PAY022)

    money to pay  (1)  lawyer . . . . . . . . . .  (2)  . . . . . . . .  (3) 

    Fill-ins:

    FN possessive/“your”

    Variable length ellipsis/null

    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:

    FN possessive/“your”

    null/variable length ellipsis

    Amount of tax withheld

    PAY053 Summary Sheet – Total Subtractions (Use with PAY022)

    Total subtractions . . . . . . . . . . . . . . . . . .  (1) 

    Fill-in:

    Amount

    PAY054 Summary Sheet – Alien Non-payment (Use with PAY022)

     (1)  residence outside of the U.S . . . . . . . . .  (2) 

    Fill-ins:

    FN possessive/“your”

    Amount

    PAY055 Summary Sheet – Prisoner Suspension (Use with PAY027)

     (1)  conviction of a felony . . . . . . . . . . . .  (2) 

    Fill-ins:

    FN possessive/“your”

    Amount withheld

    PAY056 Summary Sheet – Work Deduction (Use with PAY027)

     (1)  work and earnings over the limit . . . . . . .  (2) 

    Fill-ins:

    FN possessive/“your”

    Amount deducted

    PAY057 Summary Sheet – Medical Insurance (Use with PAY027)

    premiums for medical insurance . . . . . . . . . .  (1) 

    Fill-in:

    Premium amount withheld

    PAY058 Summary Sheet (Use with PAY020)

     (1)   (2)   (3) 

    Fill-ins:

    “and”/“through”

    Month and year

    “,”/null

    PAY059 Summary Sheet (Use with PAY020)

    including any cost of living increase  (1)   (2) 

    Fill-ins:

    “and”/null

    “,”/null

    PAY060 Summary Sheet (Use with PAY020)

    considering work and earnings through  (1) 

    Fill-in:

    Year

    PAY061 Summary Sheet (Use with PAY042)

     (1)   (2)   (3)   (4) 

    Fill-ins:

    “and”/“through”

    Month and year

    null/variable length ellipsis

    Amount/null

    PAY062 Summary Sheet (Use with PAY042)

    with premiums for medical insurance deducted $  (1) 

    Fill-in:

    Amount

    PAY063 Summary Sheet

    less monthly rounding of benefits $  (1) 

    Fill-in:

    Amount

    PAY064 Summary Sheet

    premiums for medical insurance through  (1)   (2)   (3) 

    Fill-ins:

    Month and year (COM)

    null/variable length ellipsis

    Amount

    PAY065 Summary Sheet

    additional premium due one month in advance . . . . $  (1) 

    Fill-in:

    Amount

    PAY066 Summary Sheet

    government pension offset . . . . . . . . . . . . . $  (1) 

    Fill-in:

    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:

    CPA in format $$,$$$.¢¢

    “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:

    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.

    “your”/FN (Possessive)

    PAY069 Summary Sheet

    amount paid before work was finished on claim . . . . . . $  (1) 

    Fill-in:

    CPA in format $$,$$$.¢¢

    PAY072 Regular Monthly Payment When DAA/Installment Present

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

    Fill-ins:

    “your”/“her”/“his”

    Money amount in format $$$.¢¢

    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:

    “You are”/“She is”/“He is”

    Amount of past due benefit payable

    “you”/“she”/“he”

    “you”/“her”/“him”

    Amount of installment payment

    “your”/“her”/“his”

    PAY074 Voluntary Tax Amount Withheld

    voluntary withholding for Federal taxes.....................$  (1) 

    Fill-in:

    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:

    “Your”/beneficiary's FN possessive

    MBP in the format “$$$$$.¢¢”

    COM in the format “June 1998”

    third/second Wednesday/third Wednesday/fourth Wednesday

    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:

    “You are”/“She is”/ “He is”

    Variable length ellipsis

    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:

    “her”/“his”/“your”

    NL 00725.375 “REF” UTIs – Referral

    REFC01 Caption

    If You Have Any Questions

    REF001 Referral – Domestic Address

    We invite you to visit our website at www.socialsecurity.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 your 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:

    null

    Field office address

    REF002 Referral – Foreign Address

    We invite you to visit our website at www.socialsecurity.gov to find general information about Social Security. If you have questions, please contact any Social Security office or your Federal Benefits Unit. Visit  (1)  for a list of Federal Benefits Units. You may also write to the Social Security Administration, P.O. Box 17769, Baltimore, Maryland, 21235-7769, USA. Please be sure to include your Social Security claim number if you do write. If you visit an office, please take this letter with you. It will help us answer your questions.

    If you have questions about Medicare, please visit www.medicare.gov for information.

    REF003 Referral – Domestic Address

    We invite you to visit our website at www.socialsecurity.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 your 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.socialsecurity.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:

    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 your 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:

    Local DO telephone number on TRIDE in format 1-xxx-xxx-xxxx

    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 your 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

    Fill-in:

    (1)

    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.

    NL 00725.470 “WCP” UTIs – Workers' Compensation

    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:

    NH FN “plans”/“you plan”

    “you receive”/“he receives”/“she receives”

    “your”/“your and your family's”/“his and his family's”/“her and her family's”/“his”/“her”

    “you”/“you and your family”/“he”/“he and his family”/“she”/“she and her family”

    “you were”/“he was”/“she was”/“you and your family were”/“he and his family were”/“she and her family were”

    “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:

    NH FN possessive/“Your”

    “workers' compensation”/“public disability”/“workers' compensation and public disability”

    Money amount

    “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:

    “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”

    “you”/“he”/“she”/“you and your family”/“he and his family”/“she and her family”

    “workers' compensation”/“public disability benefit payments”/“workers' compensation and public disability benefit payments”

    “your”/“his”/“her”

    “your”/“your and your family's”/“your family's”/“her”/“his”/“her and her family's”/“his and his family's”/“her family's”/“her”/“his family's”

    “your”/“his”/“her”

    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:

    “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”

    “your”/“her”/“his”

    “you”/“she”/“he”

    “you”/“she”/“he”

    Date of onset minus 5 years in the format “YYYY”

    Date of onset in the format YYYY

    Year of highest regular earnings in the format “YYYY”

    “your”/“her”/“his”

    Highest regular earnings in the format “$$$$$.¢¢”

    “you”/“she”/“he”

    “think”/“thinks”

    “You”/“She”/“He”

    “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:

    “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”

    “your”/“her”/“his”

    “you”/“she”/“he”

    “you”/“she”/“he”

    Year in the format “YYYY” *

    Year in the format “YYYY” *

    “you”/“she”/“he”

    Money amount in the format $$$$$.¢¢ *

    “you think”/NH name “thinks”

    “You”/“She”/“He”

    “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:

    BGN plus BLN, possessive/your

    NH-NAME, possessive

    “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:

    NH name

    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:

    FN possessive/“your”

    NH name possessive/“your”/“her”/“his”

    “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:

    BGN plus BLN possessive/“your”

    “workers' compensation”/“public disability benefit”/“worker's compensation and public disability benefit”

    “you receive”/“he receives”/“she receives”

    “your”/“his”/“her”

    “you”/“he”/“she”

    “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:

    your/BGN plus BLN (possessive)

    “workers' compensation payment”/“public disability payment”/“workers' compensation and public disability payments”

    Money amount

    “beginning”/“for”

    “Month YYYY”/“Month YYYY plus through plus Month YYYY”

    “your”/“his”/“her”

    “withholding”/“reducing”

    “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:

    NH name possessive

    “workers' compensation”/“public disability”/“workers' compensation and public disability”

    FN possessive/“your”

    “withholding”/“reducing”

    “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:

    “withholding”/“reducing”

    null plus FN possessive/“your”

    Show the month and year withholding or reduction began in the format “Month YYYY”

    “he is”/“she is”/“you are”

    “workers' compensation”/“public disability benefit”/“both workers' compensation and public disability benefit”

    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:

    NH name possessive/BGN plus BLN possessive/“your”

    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:

    Month YYYY

    “you”/BGN plus BLN

    “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:

    NH first name (possessive)/NH given name plus last name (possessive)/Beneficiary Full name (possessive)/“Your”

    Money amount in the format “$$$$.¢¢”

    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:

    “withholding”/“reducing”

    NH FN possessive/“your”

    Date *

    “your”/“her”/“his”

    “workers' compensation”/“public disability”/“workers' compensation and public disability”

    Prior money amount *

    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:

    “withholding”/“reducing”

    FN possessive/BGN possessive

    Month and year *

    “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:

    NH SN name (possessive)/BGN plus BLN possessive/BGN possessive/“Your”

    Earliest month/year

    “and”/null

    Month and year/null

    “This increase was”/“These increases were”

    “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:

    “workers' compensation”/“public disability”/“workers' compensation and public disability”

    Month and year in the format “September 1999”

    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:

    Month and year NH attains 65 in format “July 2012”

    NH SN possessive/BGN plus BLN possessive/BGN possessive/“your”

    “workers' compensation”/“public disability”/“workers' compensation and public disability”

    “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:

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

    “she”/“he”/“you”/FN

    “workers' compensation”/“public disability”/“workers' compensation and public disability”

    “will pay”/“started paying”

    “her”/“him”/“you”

    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:

    NH FN/“you”

    “your”/“his”/“her”

    “workers' compensation”/“workers' compensation and public disability benefit”/“public disability benefit”

    “you”/“he”/“she”

    “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:

    “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”

    “your”/“her”/“his”

    “workers' compensation”/“public disability”/“workers' compensation and public disability”

    Actual amount of excludable expenses in format $$$$$.¢¢ *

    “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:

    NH FN/“You”

    “have”/“has”

    Money amount in the format “$$$$$.¢¢”

    “your”/“her”/“his”

    “workers' compensation”/“public disability”/“workers' compensation and public disability”

    “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”

    NH FN/“you”

    Money amount in the format “$$$$.¢¢”

    Attorney fee amount in the format “$$$$.¢¢”

    Amount of medical expenses in the format “$$$$.¢¢”

    “you”/“you and your family”/“your family”/“him and his family”/“her and her family”/“him”/“her”/“her family”/“his family”

    Month and year of no offset *

    Month and year of no offset *

    “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”

    Month and year of no offset *

    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:

    NH FN/“You”

    Lump sum gross amount “$$$$$.¢¢”

    “have”/“has”

    “your”/“her”/“his”

    “workers' compensation”/“public disability”/“workers' compensation and public disability”

    “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”

    NH FN/“you”

    Money amount “$$$$.¢¢”

    Total amount of excludable expenses “$$$$.¢¢”

    Money amount “$$$$.¢¢”

    Money amount “$$$$.¢¢”

    “you”/“you and your family”/“your family”/“her”/“him”/“his family”/“her family”/“him and his family”/“her and her family”

    “additional”/“partial”/“full” *

    Month and year *

    “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

    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:

    NH FN/“You”

    “have”/“has”

    Lump sum gross amount in the format “$$$$$.¢¢”

    “your”/“her”/“his”

    “workers' compensation”/“public disability”/“workers' compensation and public disability”

    “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”

    Sum of attorney and medical expenses in the format “$$$$$.¢¢”

    Lump sum which remains in the format “$$$$$.¢¢”

    “you”/“she”/“he”

    Money amount in the format “$$$$.¢¢”

    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:

    FN possessive/“your”

    NH name possessive/“his”/“her”/“your”

    “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:

    “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”

    “you reach”/“he reaches”/“she reaches”

    “your”/“his”/“her”

    “workers' compensation”/“workers' compensation and public disability benefit”/“public disability benefit”

    “Workers' compensation”/“Workers' compensation and public disability benefit”/“Public disability benefit”

    “You”/“He”/“She”

    “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:

    “FN receives”/“you receive”

    “your”/“his”/“her”

    “you”/“he”/“she”

    “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:

    NH FN possessive/“your”

    “your”/“her”/“his”

    “workers' compensation”/“public disability”/“workers' compensation and public disability”

    “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:

    FN/“your”

    “you receive”/“he receives”/“she receives”

    “you receive”/“he receives”/“she receives”

    “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:

    Month and year NH attains FRA in format “July 2012”

    NH name possessive/“your”

    “your”/“his”/“her”

    “workers' compensation”/“public disability benefit”/“workers' compensation and public disability benefit”

    “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:

    “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”

    “you reach”/“he reaches”/“she reaches”

    Month and year NH attains FRA in format “July 2012”

    “your”/“his”/“her”

    “workers' compensation”/“public disability benefit”/“workers' compensation and public disability benefit”

    “Your”/“His”/“Her”

    “workers' compensation”/“public disability benefit”/“workers' compensation and public disability benefit”

    “You”/“He”/“She”

    “you decide”/“he decides”/“she decides”

    “you reach”/“he reaches”/“she reaches”



    NL 00725 TN 25 - Modernized Claims System (MCS) Notices - 06/13/2018