Identification Number:
NL 00720 TN 09
Intended Audience:See Transmittal Sheet
Originating Office:Systems OITEBS
Title:Manual Adjustment, Credit and Award Process (MADCAP) Beneficiary Notice Print Program
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 20 - Manual Adjustment, Credit and Award Process (MADCAP) Beneficiary Notice Print Program
Transmittal No. 09, 06/2018

Audience

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

Originating Component

OITEBS

Effective Date

Upon Receipt

Background

We are updating Program Operations Manual System (POMS) sections in NL 00720 effective with the Manual Adjustment (MADCAP) March 30, 2018 release.

Summary of Changes

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). The purpose of this initiative is to replace the Social Security number (SSN) claim number displayed on the Medicare card with the new Medicare Beneficiary Identification (MBI) number.

NL 00720.060 BEN Benefit Information
We updated the language in the BEN051 and BEN052 Universal Text Identifiers (UTIs) to specify the type of claim number by adding “Social Security” in front of “claim number”. We also revised BEN089 by replacing the SSN with the Number Holder’s name for fill-in 4.

NL 00720.065 BRR Beneficiary Reporting Responsibility
We updated the language in the BRR075 UTI to specify the type of claim number by adding “Social Security” in front of “claim number”.

NL00720.145 ENT Entitlement
We updated the language in the ENT027 and ENT028 UTIs. Technicians will no longer use the SSN of the other record for ENT027 fill-in 6 and ENT028 fill-in 3. The technician must use the number holder’s name on the other record. In addition, ENT027 fill-in 5 and ENT028 fill-in 2 now list the type of benefit the claimant is entitled.

NL00720.180 HIB Health Insurance Benefits
We updated the language in the HIB002 and HIB237 UTIs. UTI HIB022 is now obsolete. HIB002 informs the beneficiaries that they will receive a Medicare card soon. Use of the SSN as proof of coverage is no longer valid now that the Medicare numbers have changed to the new MBI number. OISP made HIB022 obsolete due to its low usage and the availability of current alternative language. We revised the language in HIB237 by replacing “claim number” with “Medicare number” in paragraph 2 and we revised fill-in 3 to show the amount.

NL00720.220 MOE Month of Entitlement
We updated language and fill-ins in the MOE004 and MOE005 UTIs to remove references to a specific SSN.

NL00720.245 OPT Overpayment
We updated the language in the OPT180 UTI to advise a beneficiary living abroad to contact SSA or the Federal Benefits Unit (FBU) that services their country when the beneficiary is overpaid and we are requesting repayment. We added a fill-in to accommodate the web addresses for obtaining a list of FBUs.

NL00720.280 REF Referral
We updated the language in the REF002 and REF140 UTIs. We revised REF002 to advise beneficiaries living abroad to contact SSA or the FBU that services their country. We added a fill-in to accommodate the web address for obtaining a list of FBUs. We revised REF140 to advise a beneficiary living abroad to contact SSA or the FBU that services their country. In addition, we changed the fill-in values.

NL00720.295 RFU Refund
We updated the language and fill-ins in the RFU001 UTI to display the amount of the overpayment in the opening sentence and to specify the type of claim number by adding “Social Security” in front of “claim number”. We also removed the last two paragraphs because this UTI requests repayment of an overpayment on records in a non-pay status.

We updated the language in the RFU001 and RFU003 UTIs. We revised the language and the fill-ins. We revised RFU012 to specify the type of claim number by adding “Social Security” in front of “claim number”. Additionally, we changed the language and the fill-in values. We revised RFU020 to advise a beneficiary living abroad to contact SSA or the FBU that services their country.



NL 00720.060 BEN Benefit Information

BEN031 NOTICE TO N/H WHEN DISABILITY ESTABLISHED IN DIB/RIB CLAIMS NO RECAL PROCESSED (J87)

(Requested)

Caption: Your Benefits

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

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Surname is

Choice 2: you are

Fill-in (2) - Systems Generated

Choice 1: her

Choice 2: his

Choice 3: your

BEN032 ADJUSTMENT IN RETROACTIVE BENEFITS IN FIRST/NEXT CHECK (M09)

(Requested)

Caption: Your Benefits

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

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Surname possessive

Choice 2: Beneficiary Full name possessive

Choice 3: your

Fill-in (2) - Requested As A One Position Alpha Character

Choice 1: (A) first

Choice 2: (B) next

Fill-in (3) - Systems Generated

Choice 1: she

Choice 2: he

Choice 3: you

BEN050 SPECIAL PAYMENT PROVISION FOR CHILDHOOD DISABILITY BENEFICIARY, WIDOW, WIDOWER, MOTHER OR PARENT WHO IS TERMINATED FOR MARRIAGE OR RE MARRIAGE (T09)

(Requested)

Caption: Your Benefits

We might still be able to pay  (1)  if  (2)  married a person who is receiving Social Security benefits. Please get in touch with us if this is true.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary's Name

Choice 2: You

Fill-in (2) - Systems Generated

Choice 1: he

Choice 2: she

Choice 3: you

BEN051 BENEFICIARY ENTITLED ON MORE THAN ONE ACCOUNT BENEFITS COMBINED INTO ONE CHECK (B16)

(Requested)

Caption: Your Benefits

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

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary's full name

Choice 2: you

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

BEN052 BENEFICIARY ENTITLED TO BENEFITS ON MORE THAN ONE ACCOUNT EACH BENEFIT PAID SEPARATELY (B18)

(Requested)

Caption: Your Benefits

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

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary's full name

Choice 2: you

BEN053 DUAL ENTITLEMENT AWARD OF PRIMARY BENEFITS WHEN BENEFICIARY PREVIOUSLY AWARDED AS AN AUXILIARY (B15)

CAUTION: Use BEN053 only on the primary (BIC A) record. If BEN053 is requested on the auxiliary record, the systems generated fill-ins cannot generate correctly, so a System Bad notice alert will result.

(Requested)

Caption: Your 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-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (2) - Systems Generated

Choice 1: (A) wife

Choice 2: (B) husband

Choice 3: (C) widow

Choice 4: (D) widower

Choice 5: (E) mother

Choice 6: (F) father

Choice 7: (G) disabled widow

Choice 8: (H) disabled widower

Choice 9: (I) disabled divorced widow

Choice 10: (J) disabled divorced widower

Fill-in (3) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (5) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (6) - Systems Generated

Choice 1: Money Amount

Fill-in (7) - Systems Generated

Choice 1: (A) wife

Choice 2: (B) husband

Choice 3: (C) widow

Choice 4: (D) widower

Choice 5: (E) mother

Choice 6: (F) father

Choice 7: (G) disabled widow

Choice 8: (H) disabled widower

Choice 9: (I) disabled divorced widow

Choice 10: (J) disabled divorced widower

Fill-in (8) - Systems Generated

Choice 1: Money Amount

Fill-in (9) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

BEN075 RECOMPUTATION PROVISION NOT PROPERLY APPLIED (A88)

(Requested)

Caption: Your Benefits

We found that we owe  (1)  money because we had not given  (2)  credit for earnings  (3)  had after we first figured  (4)  benefit amount. We will send  (5)  a back payment for past months and increase  (6)  monthly benefit amount.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's Name

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's Name

Fill-in (6) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

BEN076 NO BENEFITS PAYABLE FOR THE RETROACTIVE PERIOD (B25)

(Requested)

Caption: Your Benefits

There is a limit on how much we can pay on each Social Security record. We have paid all benefits due for  (1)  .  (2)  not due any money for this period.

Fill-in values:

Fill-in (1) - Requested As A Date In Format In Format Shown Below

Choice 1: MM/CCYY to MM/CCYY

Choice 2: MM/CCYY

Fill-in (2) - Systems Generated

Choice 1: You are

Choice 2: Beneficiary's Name is

BEN077 202(J) (1) CLAIM - ODD AMOUNT PAYABLE FOR RETROACTIVE PERIOD (B26)

(Requested)

Caption: Your Benefits

There is a limit on how much we can pay on each Social Security record. For  (1)  we have paid all but  (2)  . For this reason, we will pay  (3)  to  (4)  in the next check.

Fill-in values:

Fill-in (1) - Requested As A Date In Format In Format Shown Below

Choice 1: MM/CCYY to MM/CCYY

Choice 2: MM/CCYY

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

Choice 1: Amount

Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Total amount due

Fill-in (4) - Requested As A Alpha Character or Name

Choice 1: A=you

Choice 2: Name (Name of Beneficiary)

BEN078 W TO D CONVERSION HIGHER BENEFITS POSSIBLE ON OWN OR PRIOR SPOUSE'S RECORD (B34)

(Requested)

Caption: Other Social Security Benefits

 (1)  may be able to get a higher benefit on  (2)  own Social Security record. Also, if  (3)  married before,  (4)  may qualify for a higher benefit on the record of a prior spouse. If  (5)   (6)  may be able to get a higher benefit on  (7)  own or someone else's Social Security record, please contact us.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You

Choice 2: Beneficiary's Name

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (3) - Systems Generated

Choice 1: you were

Choice 2: he was

Choice 3: she was

Fill-in (4) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (5) - Systems Generated

Choice 1: you think

Choice 2: he thinks

Choice 3: she thinks

Fill-in (6) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (7) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

BEN079 PC JURISDICTION OF CLAIM WHERE INQUIRIES SHOULD BE FORWARDED (B38)

(System Generated)

Caption: If You Have Any Questions

If  (1)  to write to the office that handles  (2)  case, the address is:

 (3) 

 (4) 

 (5) 

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you need

Choice 2: Beneficiary's Name needs

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Choice 4: Beneficiary's name possessive

Fill-in (3) - Systems Generated

PSC Address Line 1

Fill in (4) - Systems Generated

PSC Address Line 2

Fill-in (4) Systems Generated

PSC Address Line 2

Fill-in (5) - Systems Generated

PSC Address Line 3

BEN080 NO PAYMENT AWARD ELECTED TO CONTINUE REDUCED RIB (B42)

(Requested)

Caption: Your Benefits

We approved  (1)  application for disability benefits. However, we will not pay  (2)  these benefits because  (3)  chose retirement benefits instead.  (4)  family would have received less money if  (5)  chose disability benefits.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (4) - Systems Generated

Choice 1: Your

Choice 2: His

Choice 3: Her

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

BEN081 DIB NOT PAID RIB HIGHER (B44)

(Requested)

Caption: Your Benefits

We considered  (1)  application for disability benefits. Although  (2)  eligible for disability benefits, we cannot pay  (3)  because  (4)  already receiving higher retirement benefits.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (2) Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (4) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

BEN082 CONVERSION BENEFIT INCREASE (NO RATES OR DATES) (B45)

(System Generated)

Caption: Your Benefits

 (1)  benefit amount includes the recent increase because of the change in the cost of living.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Your

Choice 2: Beneficiary's name possessive

BEN083 FUTURE ENTITLEMENT INFORMATION FOR TERMINATING YOUNG SPOUSE, B2, B1, etc. (B46)

(Requested)

Caption: Things To Remember

 (1)  may be eligible to get benefits again when  (2)  age 62. The people in any Social Security office will be glad to help  (3)  at that time.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You

Choice 2: Beneficiary Name

Fill-in (2) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (3) - Systems Generated

Choice 1: you

Choice 3: her

BEN084 (B52)

(Requested)

Caption: What We Will Pay

 (1)  still due back payments for past months.  (2)  will receive this money over a period of months. We will start paying this money to  (3)  shortly, and will send  (4)  another letter explaining how we will pay  (5)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You are

Choice 2: Beneficiary Name plus is

Fill-in (2) - Systems Generated

Choice 1: You

Choice 2: He

Choice 3: She

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (4) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

BEN085 SURVIVOR BENEFIT AWARD BASED ON MBR FROM ODO (B54)

(Requested)

Caption: The Basis For Our Decision

We have not yet looked at the facts about  (1)  case which are in an earlier file. We have requested this file from another office. However, because we do not want to hold up  (2)  checks while we get the file, we figured  (3)  benefits using the other facts we had. We will review  (4)  case after we get the file, and let  (5)  know if we need to make any changes.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

BEN086 GOVERNMENT PENSION FULL OFFSET GP ELIGIBILITY AFTER JUNE 30, 1983 (B69)

(Requested)

Caption: Your Benefits

We reduce Social Security benefits paid to  (1)  if they also receive a government pension based on their own work. We reduce benefits by two-thirds of the amount of the pension.  (2)  benefit is less than two-thirds of the amount of the pension. For this reason, we cannot pay  (3)  .

Fill-in values:

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

Choice 1: (A) husbands or wives

Choice 2: (B) widows or widowers

Fill-in (2) - Systems Generated

Choice 1: Your

Choice 2: Beneficiary's name possessive

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

BEN087 ALLEGED MISINFORMATION NOT UPHELD (B74)

(Requested)

Caption: Your Benefits

 (1)  filed  (2)  application for benefits on  (3)  .  (4)  said  (5)  did not file earlier because we gave misinformation on  (6)  . We can give  (7)  an earlier filing date if:

  •  (8)  did not file for these benefits before  (9)  because we misinformed  (10)  about  (11)  eligibility for these benefits, or the person who acted for  (12)  about  (13)  eligibility for these benefits, and

  •  (14)  did not get benefits  (15)  could have

We looked at the facts and found that we did not misinform  (16)  about  (17)  eligibility for these benefits. Therefore, we're sorry, but  (18)  cannot get an earlier filing date.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You

Choice 2: Beneficiary's Name

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Choice 4: Beneficiary's Name possessive

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

Choice 1: MM/DD/CCYY (date application was filed)

Fill-in (4) - Systems Generated

Choice 1: You

Choice 2: He

Choice 3: She

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: he

Fill-in (6) - Requested As A Date In Format Shown Below

Choice 1: MM/DD/CCYY (date alleged misinformation was given)

Fill-in (7) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (8) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (9) - Systems Generated (same as Fill -in 3)

Choice 1: MM/DD/CCYY (date application was filed)

Fill-in (10) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (11) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (12) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (13) - Systems Generated

Choice 1: your

Choice 2: his

Fill-in (14) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (15) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (16) - Systems Generated

Choice 1: you

Choice 2: the person who acted for you

Fill-in (17) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (18) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

BEN088 RIGHTS AND RESPONSIBILITIES DIB (G33)

(System Generated)

Caption: Your Responsibilities

The decisions we made on  (1)  claim are based on information  (2)  gave us. If this information changes, it could affect  (3)  benefits. For this reason, it is important that  (4)  changes to us right away. We have enclosed a pamphlet, “What You Need To Know When You Get Social Security Disability Benefits”. It will tell  (5)  what must be reported and how to report. Be sure to read the parts of the pamphlet which explain what to do if  (6)  to work or if  (7)  health improves.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (4) - Systems Generated

Choice 1: you report

Choice 2: he reports

Choice 3: she reports

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (6) - Systems Generated

Choice 1: you go

Choice 2: he goes

Choice 3: she goes

Fill-in (7) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

BEN089 INTRODUCTORY STATEMENT DUAL ENTITLEMENT AWARD AUXILIARY/SURVIVOR PRIMARY BENEFICIARY IN PAY STATUS (G40)

(Requested)

Caption:

We are writing to let  (1)  know that  (2)  entitled to monthly  (3)  benefits on the record of  (4)  beginning  (5) .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you

Choice 2: Beneficiary name

Fill-in (2) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

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

Choice 1: (A) wife's

Choice 2: (B) husband's

Choice 3: (C) widow's

Choice 4: (D) widower's

Choice 5: (E) disabled widow's

Choice 6: (F) disabled widower's

Choice 7: (G) child's

Choice 8: (H) mother's

Choice 9: (I) father's

Fill-in (4) Requested

Choice 1: Number holder's name

Fill-in (5) Requested As A Date In Format Shown Below

Choice 1: Show the Beneficiary's date of entitlement on the other record in MM/CCYY format

BEN090 REPLACEMENT NOTICE (M21)

(Requested)

Caption: None

This letter replaces our previous letter (1).

Fill-in values:

Fill-in (1) Requested as a Date in the format shown below or Alpha character

Choice 1: (A) = Null

Choice 2: dated in format MM/DD/CCYY

BEN100 ACCRUED AMOUNT PAID IN INSTALLMENTS (B24)

(Requested)

Caption: Your Benefits

A payment of  (1)  is due from  (2)  through  (3)  .  (4)  will receive this money over a period of months. We will send  (5)   (6)  more each month as part of the regular check  (7)  . We will start paying the extra money with the check  (8)  on  (9)  .

Fill-in values:

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

Total amount due

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

Choice 1: MM/CCYY

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

Choice 1: MM/CCYY

Fill-in (4) - Systems Generated

Choice 1: You

Choice 2: He

Choice 3: She

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (6) Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Amount of installment

Fill-in (7) - Systems Generated

Choice 1: you already receive

Choice 2: he already receives

Choice 3: she already receives

Fill-in (8) Choice 1: you receive

Choice 2: he receives

Choice 3: she receives

Fill-in (9) - Requested As A Date In Format Shown Below

Choice 1: Date in MM/DD/CCYY

BEN101 (GA6) BOND

(System Generated)

Caption: None

 (1)  been selected to participate in the Benefit Offset National Demonstration (BOND) project.

Fill-in values:

Fill-in (1)

Choice 1: You have

Choice 2: Beneficiary's Name has

BEN102 PAYMENT POSSIBLE TO OTHER FAMILY MEMBERS WHEN PRIMARY BENEFICIARY IS IMPRISONED/CONFINED (G41)

(Systems Generated)

Caption: Your Benefits

Even though  (1)  benefits will stop, we can pay other members of  (2)  family if they are entitled on  (3)  record.

Fill-in values:

Fill-in (1)

Choice 1: Beneficiary's Name possessive

Choice 2: your

Fill-in (2)

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (3)

Choice 1: your

Choice 2: his

Choice 3: her

BEN103 GOVERNMENT PENSION PARTIAL OFFSET GP ELIGIBILITY AFTER JUNE 30, 1983 (B68)

(Requested)

Caption: Your Benefits

We reduce Social Security benefits paid to  (1)  if they also receive a government pension based on their own work. We reduce benefits by two-thirds of the amount of the pension. For this reason, we are reducing  (2)  benefits beginning  (3)  , by  (4)  .

Fill-in values:

Fill-in (1) Request as a one position alpha character

Choice 1: (A) husbands

Choice 2: (B) wives

Choice 3: (C) widows

Choice 4: (D) widowers

Fill-in (2) System Generated

Choice 1: your

Choice 2: Beneficiary's name possessive

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

Choice 1: MM/CCYY

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

Amount of reduction

BEN104 ONE OR MORE CHECKS WITHHELD (M17)

(Requested)

Caption: Your Benefits

Therefore we are withholding  (1)   (2)   (3)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: her

Choice 3: him

Fill-in (2) - Requested As A One Position Alpha Character

Choice 1: (A) check

Choice 2: (B) checks

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

Choice 1: for MM/CCYY

Choice 2: for MM/CCYY and MM/CCYY

Choice 3: for MM/CCYY through MM/CCYY

BEN105 BOND NOTIFICATION OF ADJUSTMENT

(Requested)

Caption: None

We may have let  (1)  know earlier that we would increase  (2)  benefits to  (3)  per month due to the rise in the cost of living. We have refigured  (4)  benefits based on  (5)  participation in the benefit offset national demonstration project (BOND). This notice corrects the calculation to apply the cost of living increase to  (6)  original benefit before the reduction for BOND earnings.  (7)  new monthly amount (before deductions) is  (8)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you

Choice 2: Name

Fill-in (2) - System Generated

Choice 1: your

Choice 2: Name possessive

Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Amount (BRI/MBR incorrect monthly benefit amount)

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: Name possessive

Fill-in (5) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (6) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (7) - Systems Generated

Choice 1: Your

Choice 2: Name possessive

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

Choice 1: Amount (new offset monthly benefit amount)

BEN106 BOND – EOYR Adjustment

(Requested)

Caption: Your Benefits

Based on  (1)  earnings of  (2)  for  (3)  we should have paid  (4) 

Amount Date

 (5)   (6) 

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Name possessive

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

Choice 1: Amount (End of year BOND amount)

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

Choice 1: CCYY

Choice 2: CCYY and CCYY

Fill-in (4) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

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

Choice 1: Amount (MBC in $$$$$.¢¢ format)

Fill-in (6) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Choice 2: MM/CCYY through MM/CCYY

BEN107 BOND EOYR

(Requested)

Caption: Your Benefits

This means we paid  (1)  correctly based on the evidence  (2)  provided for the reconciliation year.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you

Choice 2: Name

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

BEN108 BOND EOYR Overpayment or Underpayment

(Requested)

Caption: Your Benefits

This  (1)  resulted from the difference in the yearly amount that  (2)  estimated  (3)  would earn during  (4)  and the actual amount that  (5)  earned, during that year. We determined the  (6)  after we recalculated  (7)  offset amount based on  (8)  actual BOND countable earnings.

Fill-in values:

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

Choice 1: (A) overpayment

Choice 2: (B) underpayment

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: Name

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (4) - Requested As A Date In Format Shown Below

Choice 1: Date (Recon year in CCYY format)

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (6) - Requested As A One Position Alpha Character (same as Fill-in 1)

Choice 1: (A) overpayment

Choice 2: (B) underpayment

Fill-in (7) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (8) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

BEN109 BOND – No Longer Eligible For BOND Project – Term Date

(Requested)

Caption: Your Benefits

 (1)  been a participant in the Benefit Offset National Demonstration (BOND) project. The special rules for the BOND project will no longer apply to  (2)  beginning  (3)  .  (4)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You have

Choice 2: Name has

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

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

Choice 1: MM/DD/CCYY

Fill-in (4) - Requested As A One Position Alpha Character

Choice 1: (A) You asked to be withdrawn from the project. If you are receiving benefit payments based on disability, your payments may stop the first month you do substantial gainful work.

Choice 2: (B) He asked to be withdrawn from the project. If he is receiving benefit payments based on disability, his payments may stop the first month he does substantial gainful work.

Choice 3: (C) She asked to be withdrawn from the project. If she is receiving benefit payments based on disability, her payments may stop the first month she does substantial gainful work.

Choice 4: (D) You are no longer eligible for the project, because you have not completed the trial work period by September 30, 2017.

Choice 5: (E) He is no longer eligible for the project, because he has not completed the trial work period by September 30, 2017.

Choice 6: (F) She is no longer eligible for the project, because she has not completed the trial work period by September 30, 2017.

Choice 7: (G) null

BEN110 BOND – No Longer Eligible For BOND Project - Explanation

(Requested)

Caption: Your Benefits

 (1)  no longer eligible for the project because  (2)   (3)  . If  (4)  receiving benefit payments based on disability,  (5)  payments may stop the first month  (6)  substantial gainful work.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You are

Choice 2: Name is

Fill-in (2) - Systems Generated

Choice 1: you have

Choice 2: he has

Choice 3: she has

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

Choice 1: (A) had benefits terminated prior to the BOND start date of participation

Choice 2: (B) participated in another demonstration project before

Choice 3: (C) moved to a foreign country

Choice 4: (D) received benefits paid by the railroad

Choice 5: (E) elected to receive benefits not based on a disability

Choice 6: (F) no longer met the BOND eligibility criteria

Fill-in (4) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (5) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (6) - Systems Generated

Choice 1: you do

Choice 2: he does

Choice 3: she does

BEN111 BOND Participation End Date

(Requested)

Caption: Your Benefits

 (1)  participation period ends  (2)  . Payments may end with the month  (3)  substantial gainful work after  (4)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Your

Choice 2: Name possessive

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

Choice 1: MM/CCYY

Fill-in (3) - Systems Generated

Choice 1: you do

Choice 2: he does

Choice 3: she does

Fill-in (4) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

BEN112 BOND Participation End Date SGA

(Requested)

Caption: Your Benefits

 (1)  participation period ends  (2)  . Since  (3)  not demonstrated an ability to perform work at a substantial gainful activity (SGA) level, payments may end in the second month following the month  (4)  an ability to perform work at an SGA level.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Your

Choice 2: Name possessive

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

Choice 1: MM/CCYY

Fill-in (3) - Systems Generated

Choice 1: you have

Choice 2: he has

Choice 3: she has

Fill-in (4) - Systems Generated

Choice 1: you demonstrate

Choice 2: he demonstrates

Choice 3: she demonstrates

BEN113 BOND Special Rules

(Requested)

Caption: What Happens When The Special Rules For BOND No Longer Apply

The special rules for the BOND project will no longer apply to  (1)  after  (2)  participation period ends. If  (3)  benefit payments based on disability after that month,  (4)  payments will stop the first month  (5)  substantial gainful work.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you

Choice 2: Name

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (3) - Systems Generated

Choice 1: you receive

Choice 2: he receives

Choice 3: she receives

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (5) - Systems Generated

Choice 1: you do

Choice 2: he does

Choice 3: she does

BEN114 BOND Adjustment

(Requested)

Caption: Why We Cannot Pay You

We cannot pay  (1)  benefits for  (2)  under the rules of the Benefit Offset National Demonstration (BOND) project. This is due to  (3)  work and earnings. This does not change any current benefits  (4)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you

Choice 2: Name

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

Choice 1: MM/CCYY

Choice 2: MM/CCYY through MM/CCYY

Fill-in (3) - Requested As A Language

Choice 1: Name (BOND participant)

Fill-in (4) - Systems Generated

Choice 1: you receive

Choice 2: he receives

Choice 3: she receives

BEN115 BOND Refund

(Requested)

Caption: None

 (1)  will soon receive a check for  (2)  . This check is for benefits due to  (3)  for  (4)  under the rules of the Benefit Offset National Demonstration (BOND) project.  (5)  due this check because of  (6)  work and earnings. This does not change any current benefits  (7)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You

Choice 2: Name

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

Choice 1: Amount (refund amount)

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (4) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Choice 2: MM/CCYY through MM/CCYY

Fill-in (5) - Systems Generated

Choice 1: You are

Choice 2: Name is

Fill-in (6) - Requested As A Language

Choice 1: Name (BOND participant)

Fill-in (7) - Systems Generated

Choice 1: you receive

Choice 2: he receives

Choice 3: she receives

BEN116 BOND Project Contact Information

(Requested)

Caption: Your Benefits

If  (1)  working and  (2)  not given us an estimate of  (3)  expected yearly earnings, please contact Abt Associates immediately. We show their contact information under the heading, “If You Have Questions About the BOND Project”. If  (4)  not give us an estimate, we may pay  (5)  incorrect benefit payments.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you are

Choice 2: Name is

Fill-in (2) - Systems Generated

Choice 1: have

Choice 2: has

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (4) - Systems Generated

Choice 1: you do

Choice 2: he does

Choice 3: she does

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

BEN117 BOND Informational (No Change)

(Requested)

Caption: None

Thank you for giving us information about  (1)  earnings for last year.  (2)  asked us to determine if there has been a change in the amount of benefits payable to  (3)  under BOND because of this information. Based on this evidence we have determined that there is no change to  (4)  monthly benefit amount for this period. This decision does not change any benefits  (5)  may be currently receiving.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Name possessive

Fill-in (2) - Systems Generated

Choice 1: You

Choice 2: He

Choice 3: She

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

BEN118 BOND Informational

(Requested)

Caption: Your Benefits

Thank you for giving us information about  (1)  earnings for the last year.  (2)  asked us to determine if there has been a change in the amount of benefits payable to  (3)  under BOND because of this information.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Name possessive

Fill-in (2) - Systems Generated

Choice 1: You

Choice 2: He

Choice 3: She

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

BEN119 BOND Request/Decision

(Requested)

Caption: None

We received a request  (1)  .

Fill-in values:

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

Choice 1: (A) for an explanation

Choice 2: (B) that we not collect the overpayment

Choice 3: (C) that we review our decision

Choice 4: (D) that we review our decision and not collect the overpayment

Choice 5: (E) that we withhold a different amount

NL 00720.065 BRR Beneficiary Reporting Responsibility

BRR004 RIGHTS AND RESPONSIBILITIES RSI, DOMESTIC OR FOREIGN (G34)

(System Generated)

Caption: Your Responsibilities

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

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

Fill-in values:

Fill-in (1)

Choice 1: Mr. Beneficiary's Name possessive

Choice 2: Ms. Beneficiary's Name possessive

Choice 3: Beneficiary's Name possessive

Choice 4: Your

Fill-in (2)

Choice 1: he

Choice 2: she

Choice 3: you

Fill-in (3)

Choice 1: his

Choice 2: her

Choice 3: you

Fill-in (4)

Choice 1: "Your Payments While You Are Outside the United States"

Choice 2: "What You Need To Know When You Get Retirement Or Survivors Benefits"

Choice 3: "What You Need To Know When You Get Social Security Disability Benefits"

Fill-in (5)

Choice 1: NULL

BRR006 DISABILITY IMPROVEMENT INFORMATION (G12)

(System Generated)

Caption: Things To Remember

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

Fill-in values:

Fill-in (1)

Choice 1: Beneficiary's Last Name

Choice 2: you

Fill-in (2)

Choice 1: she is

Choice 2: he is

Choice 3: you are

Fill-in (3)

Choice 1: she reaches

Choice 2: he reaches

Choice 3: you reach

Fill-in (4)

Choice 1: full retirement age at which FRA is effective (without additional months, if applicable) in the format: 65

Fill-in (5)

Choice 1: and

Choice 2: null

Fill-in (6)

Choice 1: If present, show additional FRA months in the format: 2

Choice 2: null

Fill-in (7)

Choice 1: months

Choice 2: null

Fill-in (8)

Choice 1: she reaches

Choice 2: he reaches

Choice 3: you reach

Fill-in (9)

Choice 1: she qualifies

Choice 2: you qualify

Choice 3: he qualifies

BRR006 INDIVIDUAL AGE 62-65 (NO RIB CLAIM FILED) (T26)

(Requested)

Caption: Things To Remember

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

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary's Last name

Choice 2: you

Fill-in (2) - Systems Generated

Choice 1: she is

Choice 2: he is

Choice 3: you are

Fill-in (3) - Systems Generated

Choice 1: she reaches

Choice 2: he reaches

Choice 3: you reach

Fill-in (4) - Systems Generated

Choice 1: full retirement age at which FRA is effective (without additional months, if applicable) in the format: 65

Fill-in (5) - Systems Generated

Choice 1: and

Choice 2: null

Fill-in (6) - Systems Generated

Choice 1: If present, show additional FRA months in the format: 2

Choice 2: null

Fill-in (7) - Systems Generated

Choice 1: months

Choice 2: null

Fill-in (8) - Systems Generated

Choice 1: she reaches

Choice 2: he reaches

Choice 3: you reach

Fill-in (9) - Systems Generated

Choice 1: she qualifies

Choice 2: you qualify

Choice 3: he qualifies

BRR016 RIGHTS AND RESPONSIBILITIES NON-DIB, RRB DOM. OR FOR (G35)

(System Generated)

Caption: Your Responsibilities

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

Fill-in values:

NONE

BRR026 REPORTING RESPONSIBILITIES - PROVISIONAL BENEFITS (P11)

(Requested)

Caption: Your Responsibilities

You must tell us right away about any changes that may affect  (1)  benefits. You should tell us if:

  •  (2)  mailing address;

  •  (3)  to work or  (4)  work hours;

  •  (5)  doctor says  (6)  condition has improved;

  •  (7)  to leave the United States for 30 days or more;

  •  (8)  been convicted of a criminal offense; or

  •  (9)  benefits have been reinstated as either a disabled widow/widower or a disabled adult child.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Choice 4: null

Fill-in (2) - Systems Generated

Choice 1: You change your

Choice 2: He changes his

Choice 3: She changes her

Fill-in (3) - Systems Generated

Choice 1: You return

Choice 2: He returns

Choice 3: She returns

Fill-in (4) - Systems Generated

Choice 1: you increase your

Choice 2: he increases his

Choice 3: she increases her

Fill-in (5) - Systems Generated

Choice 1:Your

Choice 2: His

Choice 3: Her

Fill-in (6) - Systems Generated

Choice 1:Your

Choice 2: His

Choice 3: Her

Fill-in (7) - Systems Generated

Choice 1: You plan

Choice 2: He plans

Choice 3: She plans

Fill-in (8) - Systems Generated

Choice 1: You have

Choice 2: He has

Choice 3: She has

Fill-in (9) - Systems Generated

Choice 1: You marry and your

Choice 2: He marries and his

Choice 3: She marries and her

BRR040 FACILITY OF PAYMENT WORKER'S RESPONSIBILITIES (G36)

(System Generated)

Caption: Your Responsibilities

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

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

  • Another family member starts working; or

  • A family member moves out of the household.

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

Fill-in values:

Fill-in (1)

Choice 1: you

Choice 2: she

Choice 3: he

Fill-in (2)

Choice 1: expects

Choice 2: expects

BRR057 RIB BENEFITS AT 62 MAY BE HIGHER FOR FAMILY THAN DIB (J72)

(Requested)

Caption: Things To Remember

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

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary's Name

Choice 2: you

Fill-in (2) - Systems Generated

Choice 1: reach

Choice 2: reaches

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: her

Choice 3: his

Fill-in (4) - Systems Generated

Choice 1: you file

Choice 2: he files

Choice 3: she files

BRR075 REMINDER TO INCLUDE CLAIM NUMBER ON CORRESPONDENCE (G80)

(System Generated)

Caption: If You Disagree With The Decision

Always give  (1)  Social Security claim number on any letter or notice you send about  (2)  claim.

Fill-in values:

Fill-in (1) Systems Generated

Choice 1: Beneficiary's Name possessive

Choice 2: your

Fill-in (2) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

BRR076 REMINDER TO KEEP LETTER AS PERMANENT RECORD (G81)

(System Generated)

Caption: If You Disagree With The Decision

KEEP AS A PERMANENT RECORD – DO NOT DESTROY

Fill-in values:

NONE

BRR078 (WB6) BOND

Caption:

(System Generated)

Because of  (1)  work and earnings, no benefits are payable to you at this time under the rules of the Benefit Offset National Demonstration (BOND) project. If  (2)  work or earnings change, we may be able to pay some benefits in the future.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: BOND Beneficiary's Name possessive

Fill-in (2) - Systems Generated

Choice 1: BOND Beneficiary's Name possessive

BRR079 (WB7) BOND

Caption:

(System Generated)

Because of  (1)  work and earnings, benefits are payable to you at this time under the rules of the Benefit Offset National Demonstration (BOND) project. If  (2)  work or earnings change, some benefits may not be payable in the future.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: BOND Beneficiary's Name possessive

Fill-in (2) - Systems Generated

Choice 1: BOND Beneficiary's Name possessive

BRR080 REMINDER TO REPORT CHANGES IN WORK OR EARNINGS (W67)

(Requested)

Caption: Your Responsibilities

Please be sure to let us know right away if  (1)  work or earnings change, because changes could affect the amount of  (2)  benefits.

Fill-in values:

Fill-in (1) – System Generated

Choice 1: your

Choice 2: Beneficiary's Name possesive

Fill-in (2) – System Generated

Choice 1: your

Choice 2: his

Choice 3: her

BRRR13 CURRENT YEAR S.E.I. USED PENDING RECEIPT OF TAX RETURN (C06)

(Requested)

Caption: Your responsibility

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

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

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Your

Choice 2: Her

Choice 3: His

Fill-in (2) - Requested As A Year In Format CCYY

Choice 1: Year

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (4) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (5) - Systems Generated

Choice 1: your

Choice 2: her

Choice 3: his

NL 00720.145 ENT Entitlement

ENT001 STUDENT ENFORCEMENT (B22)

(System Generated)

Caption: Your Responsibility

We are writing to let you know that  (1)   (2)  for child's payments as a student. Based on the information we have,  (3)  benefits will continue through  (4)  . We will send another letter when we stop  (5)  benefits.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's Name possessive

Fill-in (2) - Systems Generated

Choice 1: qualify

Choice 2: qualifies

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: her

Choice 3: his

Fill-in (4) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (5) - Systems Generated

Choice 1: your

Choice 2: her

Choice 3: his

ENT015 RIB ALLOWANCE SUBSEQUENT DIB DENIAL (J17)

(Requested)

Caption: Other Social Security Benefits

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

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary's Last Name

Choice 2: you

Fill-in (2) - Systems Generated

Choice 1: she is

Choice 2: he is

Choice 3: you are

ENT027 DUAL ENTITLEMENT AWARD — PRIMARY AND AUXILIARY/SURVIVOR BENEFITS AWARDED SIMULTANEOUSLY — ONE NOTICE SENT (A38)

(Requested)

Caption: None

 (1)  entitled to monthly  (2)  benefits beginning  (3)  .  (4)  also entitled to  (5)  benefits on the record of  (6)  beginning  (7)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You are

Choice 2: He is

Choice 3: She is

Fill-in (2) - Systems Generated

Choice 1: disability

Choice 2: retirement

Fill-in (3) - Systems Generated

Choice 1: MM/CCYY

Fill-in (4) - Systems Generated

Choice 1: You are

Choice 2: He is

Choice 3: She is

Fill-in (5) - Requested As A One Position Alpha Character

Choice 1: (A) wife's

Choice 2: (B) husband's

Choice 3: (C) widow's

Choice 4: (D) widower's

Choice 5: (E) mother's

Choice 6: (F) father's

Choice 7: (G) disabled widow's

Choice 8: (H) disabled widower's

Choice 9: (I) disabled divorced widow's

Choice 10: (J) disabled divorced widower's

Choice 11: (K) Child's

Fill-in (6) - Requested

Choice 1: Number holder's name on the other record

Fill-in (7) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

ENT028 DUAL ENTITLEMENT - PRIMARY AWARD - SIMULTANEOUS ENTITLEMENT TO AUXILIARY/SURVIVOR BENEFITS - SEPARATE PAYMENTS (A40)

(Requested)

Caption: Your Benefits

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

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You are

Choice 2: He is

Choice 3: She is

Fill-in (2) - Requested As A One Position Alpha Character

Choice 1: (A) wife's

Choice 2: (B) husband's

Choice 3: (C) widow's

Choice 4: (D) widower's

Choice 5: (E) mother's

Choice 6: (F) father's

Choice 7: (G) disabled widow's

Choice 8: (H) disabled widower's

Choice 9: (I) disabled divorce widow's

Choice 10: (J) disabled divorced widower's

Choice 11: (K) Child's

Fill-in (3) - Requested

Choice 1: Number holder on the other record

Fill-in (4) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: her

Choice 3: him

ENT029 DUAL ENTITLEMENT AUXILIARY/SURVIVOR AWARD - SIMULTANEOUS ENTITLEMENT ON PRIMARY RECORD - SEPARATE PAYMENTS (A41)

(Requested)

Caption: Your Benefits

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

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You are

Choice 2: He is

Choice 3: She is

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: her

Choice 3: his

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

Choice 1: MM/CCYY

Fill-in (4) - Systems Generated

Choice 1: you

Choice 2: her

Choice 3: him

ENT038 BENEFITS REDUCED TO ZERO UNDER DIB FAMILY MAXIMUM PROVISIONS (J74)

(Requested/Generated)

Caption: Your Benefits

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-in values:

Fill-in (1) - Systems Generated

Choice 1: Your

Choice 2: Full name possessive

Fill-in (2) - Requested As A One Position Alpha Character

Choice 1: (A) spouse's

Choice 2: (B) child's

Choice 3: (C) parent's

Fill-in (3) - Systems Generated

Choice 1: His

Choice 2: Her

Choice 3: Your

Fill-in (4) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY (DOEC)

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: her

Choice 3: him

Fill-in (6) - Requested As A Language

Choice 1: Number holders full name

ENT048 ACCRUED BENEFITS TEMPORARILY WITHHELD PENDING FINAL RECOMMENDATION (B23)

(Requested)

Caption: Your Benefits

We are withholding payment for  (1)  until we decide the best way

to make payments.

Fill-in values:

Fill-in (1) - Requested As A Date In Format Shown Below

Choice 1: MM/YYYY

Choice 2: MM/YYYY and MM/YYYY

Choice 3: MM/YYYY through MM/YYYY

ENT051 HI DATE OF ENTITLEMENT (H10)

(Requested/Generated)

Caption: Information About Medicare

You are entitled to hospital insurance under Medicare beginning  (1)  .

Fill-in values:

Fill-in (1) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

ENT052 SMI DATE OF ENTITLEMENT (H12)

(Requested/Generated))

Caption: Information About Medicare

You are entitled to medical insurance under Medicare beginning  (1)  .

Fill-in values:

Fill-in (1) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

ENT056 NO PAYMENT AWARD ENTITLED TO AN EQUAL OR LARGER BENEFIT ON ANOTHER RECORD (B41)

(Requested)

Caption: Your Benefits

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-in values:

Fill-in (1) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (2) - Requested As A One Position Alpha Character

Choice 1: (A) wife's

Choice 2: (B) husband's

Choice 3: (C) widow's

Choice 4: (D) widower's

Choice 5: (E) mother's

Choice 6: (F) father's

Choice 7: (G) disabled widow's

Choice 8: (H) disabled widower's

Choice 9: (I) disabled divorced widow's

Choice 10: (J) disabled divorced widower's

Choice 11: (K) child's

Fill-in (3) - Systems Generated

Choice 1: him

Choice 2: you

Choice 3: her

Fill-in (4) - Requested As A Language

Choice 1: Number holder name

Fill-in (5) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

ENT062 MONTH OF ENTITLEMENT CONFIRMED (A52)

(Requested)

Caption: Your Benefits

We reviewed  (1)  record. When  (2)  applied,  (3)  asked us to start  (4)  benefits in  (5)  . We found that  (6)  is still the month when benefits should start.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary Name possessive

Choice 2: your

Fill-in (2) - Systems Generated

Choice 1: he

Choice 2: she

Choice 3: you

Fill-in (3) - Systems Generated

Choice 1: he

Choice 2: she

Choice 3: you

Fill-in (4) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (5) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (6) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

ENT063 BENEFICIARY ENTITLED ON TWO ACCOUNTS A BENEFITS (PREVIOUSLY AWARDED) TO BE COMBINED WITH WIDOW(ER)'S BENEFITS AND PAYMENT OF LUMP-SUM (B07)

(Requested)

Caption: What We Will Pay

The check, which includes the money  (1)  due through  (2)  , will also include a lump-sum payment of  (3)  . This is a one-time payment we make because of a worker's death.

After that, we will send  (4)  benefits in one check each month. The check will include  (5)  which  (6)  due on  (7)  own Social Security record and  (8)  which  (9)  due on the other record.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you are

Choice 2: Beneficiary Name is

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

Choice 1: MM/CCYY

Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Amount of lump-sum

Fill-in (4) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

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

Choice 1: Amount MBP

Fill-in (6) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (7) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

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

Choice 1: Amount MBP

Fill-in (9) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

ENT064 UNDERPAYMENT PAID TO OTHER BENEFICIARY (B08)

(Requested)

Caption: What We Will Pay

Your  (1)  check includes  (2)  which we owed  (3)  .

Fill-in values:

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

Choice 1: (A) next

Choice 2: (B) first

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

Choice 1: Amount of underpayment

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

Choice 1: (A) your wife

Choice 2: (B) your husband

Choice 3: (C) your father

Choice 4: (D) your mother

Choice 5: name of beneficiary

ENT065 SIMULTANEOUS A AND AB AWARDS (B17)

(Requested)

Caption: Other Social Security Benefits

We are still working on  (1)   (2)  claim for spouse's benefits. When we decide whether or not  (3)  is entitled to benefits, we will send  (4)  a letter.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary name possessive

Fill-in (2) - Requested As A One Position Alpha Character

Choice 1: (A) wife's

Choice 2: (B) husband's

Fill-in (3) - Systems Generated

Choice 1: he

Choice 2: she

Fill-in (4) - Systems Generated

Choice 1: him

Choice 2: her

ENT066 AUXILIARY CLAIM PENDING (C07)

(Requested)

Caption: Things To Remember

We are still working on  (1)  claim. When we decide whether or not  (2)  entitled to benefits, we will send another letter to give our decision.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary's Name possessive

Choice 2: your

Fill-in (2) - Systems Generated

Choice 1: he is

Choice 2: she is

Choice 3: you are

ENT067 UNDERPAYMENT DUE TO DEATH OF BENEFICIARY SHARED WITH INDIVIDUAL(S) OF EQUAL ENTITLEMENT (C09)

(Requested)

Caption: What We Will Pay

This check includes  (1)  , which is part of the money which was due  (2)  . Each person who is eligible for part of this money will get an equal share. The amount shown above is  (3)  share.

Fill-in values:

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

Choice 1: Amount

Fill-in (2) - Requested As A Language

Choice 1: Name of deceased individual

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: Beneficiary name possessive

ENT068 RIGHTS AND RESPONSIBILITIES DOMESTIC CONVERSION FROM DIB (G14)

(System Generated)

Caption: Your Responsibilities

It is important that you report changes that could affect  (1)  benefits to us right away. To explain these changes, we have enclosed a pamphlet, When You Get Social Security Retirement or Survivor Benefits. What You Need To Know. It will tell you what must be reported and how to report. Please be sure to read the part of the pamphlet which explains how earnings from work could change  (2)  payments.

Fill-in values:

Fill-in (1)

Choice 1: your

Choice 2: Beneficiary name possessive

Fill-in (2)

Choice 1: your

Choice 2: Beneficiary name possessive

ENT069 RIGHTS AND RESPONSIBILITIES FOREIGN CONVERSION FROM DIB (G15)

(System Generated)

Caption: Your Responsibilities

It is important that you report changes that could affect  (1)  benefits to us right away. To explain these changes, we have enclosed a pamphlet, Your Social Security Checks While You Are Outside the United States. It will tell you what must be reported and how to report. The pamphlet explains that we may not pay  (2)  if  (3)  more than 45 hours in a month.

Fill-in values:

Fill-in (1)

Choice 1: your

Choice 2: Beneficiary name possessive

Fill-in (2)

Choice 1: you

Choice 2: Beneficiary's name

Fill-in (3)

Choice 1: you work

Choice 2: he works

Choice 3: she works

ENT070 DATE OF BIRTH ESTABLISHED DIFFERENT FROM THAT ALLEGED OR DATE ESTABLISHED BEFORE ATTAINMENT OF RETIREMENT AGE (C08)

(Requested/Generated)

Caption: The Basis For Our Decision

Based on the information given to us,  (1)  born on  (2)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary's name + was

Choice 2: you were

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

MM/DD/CCYY

ENT071 DIB TO RIB CONVERSION (GA3)

(System Generated)

Caption: Your Benefits

We are changing the type of benefit  (1)  from Social Security. Beginning  (2)  ,  (3)  entitled to retirement benefits.  (4)  no longer entitled to disability benefits because  (5)  reached full retirement age.

Fill-in values:

Fill-in (1)

Choice 1: Name + receives

Choice 2: you receive

Fill-in (2)

Choice 1: MM/CCYY

Fill-in (3)

Choice 1: he is

Choice 2: she is

Choice 3: you are

Fill-in (4)

Choice 1: He is

Choice 2: She is

Choice 3: You are

Fill-in (5)

Choice 1: he has

Choice 2: she has

Choice 3: you have

ENT075 NEW BENEFICIARY ENTITLED TO BENEFITS (J79)

(Requested)

Caption: Your Benefits

Since  (1)  now entitled to benefits, we changed the amount we can pay  (2)  beginning  (3)  . We will continue to pay this new monthly amount as long as  (4)   (5)  payments.

Fill-in values:

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

Choice 1: (A) name of terminated beneficiary is

Choice 2: (B) names of terminated beneficiaries are

Choice 3: (C) you are

Fill-in (2) - Systems Generated

Name (or names) of previously entitled beneficiary (or beneficiaries)

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

MM/CCYY (date of adjustment)

Fill-in (4) - Systems Generated

Choice 1: Beneficiary's Name + receives

Choice 2: you receive

Fill-in (5) - Requested As A One Position Alpha Character

Choice 1: (A) workers' compensation

Choice 2: (B) public disability

Choice 3: (C) workers' compensation and public disability

NL 00720.180 HIB Health Insurance Benefits

HIB002 TEMPORARY SUBSTITUTION OF NOTICE FOR HEALTH INSURANCE CARD (H23)

(Requested/Generated)

Caption: Information About Medicare

 (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-in values:

Fill-in (1) - Systems Generated

Choice 1: You

Choice 2: Beneficiary's Name

Fill-in (2) - Systems Generated

Choice 1: You should

Choice 2: He should

Choice 3: She should

Fill-in (3) - Systems Generated

Choice 1: you need

Choice 2: he needs

Choice 3: she needs

Fill-in (4) - Systems Generated

Choice 1: you have

Choice 2: he has

Choice 3: she has

Fill-in (5) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

HIB003 MEDICAL CLAIMANT ENROLLED BEFORE INITIAL ENROLLMENT PERIOD (H42)

(Requested)

Caption: Information About Medicare

 (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-in values:

Fill-in (1) - Systems Generated

Choice 1: You are

Choice 2: She is

Choice 3: He is

Fill-in (2) - Systems Generated

Choice 1: medical insurance coverage

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: her

Choice 3: his

Fill-in (4) - Systems Generated

Choice 1: You

Choice 2: She

Choice 3: He

Fill-in (5) - Systems Generated

Choice 1: Month and Year

Fill-in (6) - Systems Generated

Choice 1: Month and Year

Fill-in (7) - Systems Generated

Choice 1: You

Choice 2: She

Choice 3: He

Fill-in (8) - Systems Generated

Choice 1: you

Choice 2: she

Choice 3: he

Fill-in (9) - Systems Generated

Choice 1: reach

Choice 2: reaches

HIB004 MEDICAL CLAIMANT ENROLLED AFTER IEP AND BEFORE GENERAL ENROLLMENT PERIOD (H43)

(Requested)

Caption: Information About Medicare

 (1)  not entitled to  (2)  under Medicare because  (3)  application was filed too late.  (4)  should have filed before  (5)  . However,  (6)  g 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-in values:

Fill-in (1) - Systems Generated

Choice 1: You are

Choice 2: She is

Choice 3: He is

Fill-in (2) - Systems Generated

Choice 1: medical insurance coverage

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: her

Choice 3: his

Fill-in (4) - Systems Generated

Choice 1: You

Choice 2: She

Choice 3: He

Fill-in (5) - Systems Generated

Choice 1: Month and Year

Fill-in (6) - Systems Generated

Choice 1: you

Choice 2: she

Choice 3: he

HIB011 PREMIUM BILLING FOR HOSPITAL INSURANCE ONLY (H46)

(Requested)

Caption: Information About Medicare

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

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: her

Choice 3: his

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

Choice 1: HPAC amount

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

Choice 1: (A) this premium

Choice 2: (B) the combined premium for hospital and medical insurance

Choice 3: (C) premiums

HIB015 CIVIL SERVICE BUY-IN (H31)

(Requested/Generated)

Caption: Information About Medicare

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

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary's Name possessive

Choice 2: your

Fill-in (2) - Systems Generated

Choice 1: him

Choice 2: her

Choice 3: you

HIB019 BENEFICIARY IS NOT ENTITLED TO MEDICARE PART A FOR FREE BUT ELIGIBLE TO BUY MEDICARE PART A (HOSPITAL INSURANCE) FOR A FEE

(Requested)

Caption: None

 (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-in values:

Fill-in (1) - Systems Generated

Choice 1: You

Choice 2: Beneficiary's full name

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (3) - Systems Generated

Beneficiary's monthly cost for Part A

HIB021 DUAL ENTITLEMENT AUXILIARY/SURVIVOR AWARD AFTER PRIMARY - MEDICARE ENTITLEMENT PREVIOUSLY ESTABLISHED (H84)

(Requested)

Caption: Information About Medicare

This letter does not affect  (1)  Medicare benefits.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 1: his

Choice 1: her

HIB033 HI COVERAGE - NO SMI ELECTED - PROVISIONAL BENEFITS CASE (P06)

(Requested)

Caption: Information About Medicare

 (1)  will have Medicare hospital insurance (Part A) coverage while  (2)  receiving these provisional benefits.  (3)  coverage will begin  (4)  .  (5)  hospital insurance (Part A) is free. If  (6)  provisional benefits end because  (7)  received 6 months of payments, then  (8)  Medicare coverage will end at the same time. If  (9)  provisional benefits end for any other reason, then  (10)  will get another letter telling  (11)  about  (12)  Medicare coverage.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You

Choice 2: Beneficiary's name

Fill-in (2) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (3) - Systems Generated

Choice 1: You

Choice 2: His

Choice 3: Her

Fill-in (4) - Systems Generated

Choice 1: Month CCYY (date Medicare coverage begins)

Fill-in (5) - Systems Generated

Choice 1: Your

Choice 2: His

Choice 3: Her

Fill-in (6) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (7) - Systems Generated

Choice 1: you have

Choice 2: he has

Choice 3: she has

Fill-in (8) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (9) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (10) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (11) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (12) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

HIB036 SMI COVERAGE ELECTED DURING PROVISIONAL PERIOD - PROVISIONAL BENEFITS CASE (P07)

(Requested)

Caption: Information About Medicare

 (1)  will have Medicare hospital insurance (Part A) and medical insurance (Part B) coverage while  (2)  receiving these provisional benefits.  (3)  coverage will begin  (4)  .  (5)  hospital insurance (Part A) is free.  (6)  medical insurance (Part B) premium will be deducted from the monthly payment. If  (7)  provisional benefits end because  (8)  received 6 months of payments, then  (9)  Medicare coverage will end at the same time. If  (10)  provisional benefits end for any other reason, then  (11)  will get another letter telling  (12)  about  (13)  g Medicare coverage.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You

Choice 2: Beneficiary's Name

Fill-in (2) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (3) - Systems Generated

Choice 1: Your

Choice 2: His

Choice 3: Her

Fill-in (4) - Systems Generated

Choice 1: Month CCYY (date Medicare coverage begins)

Fill-in (5) - Systems Generated

Choice 1: Your

Choice 2: His

Choice 3: Her

Fill-in (6) - Systems Generated

Choice 1: Your

Choice 2: His

Choice 3: Her

Fill-in (7) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (8) - Systems Generated

Choice 1: you have

Choice 2: he has

Choice 3: she has

Fill-in (9) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (10) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (11) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (12) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (13) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

HIB039 INITIAL PREMIUM BILLING BENEFITS SUSPENDED OR DEFERRED STATUS MATURING BEYOND CURRENT YEAR (H60)

(Requested/Generated)

Caption: Information About Medicare

We will charge a monthly premium for  (1)  medical insurance under Medicare. The first bill we send will be for all premiums now due. After that, each bill we send will be for a 3-month period, and will be sent to you shortly before payment is due.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

HIB040 MEDICARE COVERAGE WILL CONTINUE BASED ON EXTENDED MEDICARE PROVISIONS - PROVISIONAL BENEFITS CASE (P08)

(Requested)

Caption: Information About Medicare

 (1)  Medicare coverage will continue while  (2)  receiving these provisional benefits.  (3)  hospital insurance (Part A) is free. If  (4)  medical insurance (Part B)  (5)  will no longer get a bill for the premium.  (6)  premium will be deducted from the monthly payment.  (7)  Medicare coverage may end if we deny  (8)  request for reinstatement.  (9)  will get another letter telling  (10)  if  (11)  Medicare coverage will end.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Your

Choice 2: Beneficiary's Name

Fill-in (2) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (3) - Systems Generated

Choice 1: Your

Choice 2: His

Choice 3: Her

Fill-in (4) - Systems Generated

Choice 1: you have

Choice 2: he has

Choice 3: she has

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (6) - Systems Generated

Choice 1: Your

Choice 2: His

Choice 3: Her

Fill-in (7) - Systems Generated

Choice 1: Your

Choice 2: His

Choice 3: Her

Fill-in (8) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (9) - Systems Generated

Choice 1: You

Choice 2: He

Choice 3: She

Fill-in (10) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (11) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

HIB041 HI TERMINATION DUE TO DIB CESSATION OR MARRIAGE OF DAC (H80)

(Requested/Generated)

Caption: Information About Medicare

Since  (1)   (2)  no longer entitled to monthly Social Security benefits, we are stopping  (3)  hospital insurance coverage under Medicare.  (4)  hospital insurance coverage ends on the last day of  (5)  .  (6)  g Medicare card will no longer be valid after coverage ends, so please tear it up.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary name

Choice 2: you

Fill-in (2) - Systems Generated

Choice 1: is

Choice 2: are

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (4) - Systems Generated

Choice 1: Your

Choice 2: His

Choice 3: Her

Fill-in (5) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (6) - Systems Generated

Choice 1: Beneficiary's Name possessive

Choice 2: Your

HIB043 MEDICARE COVERAGE WILL CONTINUE BASED ON ESRD - PROVISIONAL BENEFITS CASE (P09)

(Requested)

Caption: Information About Medicare

 (1)  already entitled to  (2)  because  (3)  enrolled based on a kidney condition. If  (4)  medical insurance (Part B)  (5)  will no longer get a bill for the premium.  (6)  premium will be deducted from the monthly payment.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You are

Choice 2: Beneficiary's Name + is

Fill-in (2) - Requested As A One Position Alpha Character

Choice 1: (A) hospital insurance (Part A)

Choice 2: (B) hospital insurance (Part A) and medical insurance (Part B)

Fill-in (3) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (4) - Systems Generated

Choice 1: you have

Choice 2: he has

Choice 3: she has

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (6) - Systems Generated

Choice 1: Your

Choice 2: His

Choice 3: Her

HIB045 MEDICARE CLOSED PERIOD - PROVISIONAL BENEFITS CASE (P10)

(Requested)

Caption: Information About Medicare

 (1)   (2)  coverage under Medicare from  (3)  through  (4)  . The Medicare coverage has ended because  (5)  no longer receiving provisional benefits.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You have

Choice 2: She has

Choice 3: He has

Fill-in (2) - Requested As A One Position Alpha Character

Choice 1: (A) hospital insurance (Part A)

Choice 2: (B) hospital insurance (Part A) and medical insurance (Part B)

Fill-in (3) - Systems Generated

Choice 1: MM/CCYY (date Medicare coverage begins)

Fill-in (4) - Systems Generated

Choice 1: MM/CCYY (date Medicare coverage begins)

Fill-in (5) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

HIB052 SMI REFUSAL PROCEDURE (H24)

(Requested)

Caption: Information About Medicare

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.

Fill-in values:

None

HIB061 HMO ENROLLMENT CIVIL SERVICE INVOLVEMENT (H54)

(Requested)

Caption: Information About Medicare

The Office of Personnel Management will continue to deduct  (1)  medical insurance premiums from  (2)  annuity checks.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary Name, possessive

Choice 2: your

Fill-in (2) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

HIB092 HMO DISENROLLMENT. PRIVATE PREMIUM PAYMENT WILL CONTINUE. PENALTY INVOLVED. (H56)

(Requested)

Caption: Information About Medicare

 (1)  State or local government retirement system will continue to pay  (2)  Medicare medical insurance late enrollment premium penalty.  (3)  must continue to pay the basic Medicare medical insurance premium.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary Name, possessive

Choice 2: Your

Fill-in (2) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Choice 4: the

Fill-in (3) - Systems Generated

Choice 1: He

Choice 2: She

Choice 3: You

Choice 4: Beneficiary's Name

HIB093 HMO DISENROLLMENT. STATE WILL CONTINUE TO PAY PREMIUMS (H55)

(Requested)

Caption: Information About Medicare

Our records show that  (1)  will continue to pay the premiums for  (2)  Medicare  (3)  insurance coverage.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: the State

Choice 2: an organization

Fill-in (2) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (3) - Systems Generated

Choice 1: hospital and medical

Choice 2: medical

HIB095 CHANGE IN DATE OF ENTITLEMENT TO SMI (H13)

(Requested or Systems Generated)

Caption: Information About Medicare

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

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary Name possessive

Fill-in (2) - Requested As A One Position Alpha Character

Choice 1: (A) hospital

Choice 2: (B) medical

Choice 3: (C) hospital and medical

Fill-in (3) - Systems Generated

Choice 1: Your

Choice 2: His

Choice 3: Her

Fill-in (4) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (5) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

HIB139 HEALTH INSURANCE – PENALTY FOR LATE ENROLLMENT (H21-2)

(Requested/Generated)

Caption: Information About Medicare

This medical insurance premium includes a penalty because  (1)  enrolled later than  (2)  could have.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's Name

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

HIB152 SMI DECLINED DURING IEP OR SMI DECLINED WHEN OFFERED THROUGH EQUITABLE RELIEF (H05)

(Requested/Generated)

Caption: Information About Medicare

 (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-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary's full name

Choice 2: You

Fill-in (2) - Systems Generated

Choice 1: has

Choice 2: have

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

Choice 1: Show HI-START plus 3 months MM/CCYY

Fill-in (4) - Systems Generated

Choice 1: you do

Choice 2: he does

Choice 3: she does

Fill-in (5) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (6) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (7) - Systems Generated

Choice 1: you have

Choice 2: he has

Choice 3: she has

Fill-in (8) - Systems Generated

Choice 1: Your

Choice 2: His

Choice 3: Her

Fill-in (9) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (10) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (11) - Systems Generated

Choice 1: you sign

Choice 2: he signs

Choice 3: she signs

Fill-in (12) - Systems Generated

Choice 1: you want

Choice 2: he wants

Choice 3: she wants

Fill-in (13) - Systems Generated

Show HI-START plus 3 months MM/CCYY

Fill-in (14) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (15) - Systems Generated

Choice 1: you sign

Choice 2: he signs

Choice 3: she signs

Fill-in (16) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (17) - Systems Generated

Choice 1: you sign

Choice 2: he signs

Choice 3: she signs

Fill-in (18) - Systems Generated

Choice 1: Beneficiary's full name

Choice 2: You

Fill-in (19) - Systems Generated

Choice 1: You

Choice 2: He

Choice 3: She

Fill-in (20) - Systems Generated

Choice 1: you meet

Choice 2: he meets

Choice 3: she meets

Fill-in (21) - Systems Generated

Choice 1: You are

Choice 2: He is

Choice 3: She is

Fill-in (22) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill (23) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (24) Systems Generated

Choice 1: You are

Choice 2: He is

Choice 3: She is

Fill-in (25) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (26) Systems Generated

Choice 1: You

Choice 2: He

Choice 3: She

Fill-in (27) Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (28) Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (29) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (30) Systems Generated

Choice 1: You

Choice 2: He

Choice 3: She

Fill-in (31) Systems Generated

Choice 1: you have

Choice 2: he has

Choice 3: she has

Fill-in (32) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (33) Systems Generated

Choice 1: you need

Choice 2: he needs

Choice 3: she needs

Fill-in (34) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

HIB157 CHILDREN'S HEALTH INSURANCE PROGRAM (H18)

(Requested/Generated)

Caption: Health Insurance For Children

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.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: www.insurekidsnow.gov

HIB170 MONTHLY BENEFITS TERMINATED - HI/SMI CONTINUES - LAF U (H90)

(Requested/Generated)

Caption: Information About Medicare

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)  g every 3 months for the premiums.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary name is

Choice 2: you are

Fill-in (2) - Systems Generated

Choice 1: he

Choice 2: she

Choice 3: you

Fill-in (3) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (4) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (5) - Systems Generated

Choice 1: her

Choice 2: him

Choice 3: your

HIB171 CRD ENTITLEMENT MONTHLY BENEFITS TERMINATED HI/SMI CONTINUES STATE BUY-IN CONTINUES (H91)

(Requested/Generated)

Caption: Information About Medicare

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-in values:

Fill-in (1) - Systems Generated

Choice 1: you are

Choice 2: Beneficiary's Name is

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (4) - Systems Generated

Choice 1: you live

Choice 2: he lives

Choice 3: she lives

Fill-in (5) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

HIB175 SMI PREMIUMS/ARREARAGE DEDUCTED FROM PMA ORCMA

(System Generated)

Caption: Information About Medicare

We are deducting past-due premiums from  (1)  check.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Name possessive

Choice 2: your

HIB182 IRMAA – MEDICARE PART B PREMIUM BASED ON INCOME (HA9)

(Requested/Generated)

Caption: Information About Medicare

In an earlier letter, we told you that  (1)  Medicare Part B (medical insurance) premium includes:

  • the standard Part B premium amount,

  • any surcharge that may apply for late enrollment or reenrollment, and

  • an income-related monthly adjustment amount (IRMAA).

If  (2)  prescription drug coverage,  (3)  also must pay a prescription drug coverage IRMAA. The IRMAA is in addition to  (4)  monthly premium. We base the IRMAA on  (5)  income. We deduct the IRMAA from  (6)  monthly Social Security benefits, regardless of how  (7)  premiums.

.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name Possessive

Fill-in (2) - Systems Generated

Choice 1: you have

Choice 2: she has

Choice 3: he has

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: she

Choice 3: he

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: her

Choice 3: his

Fill-in (5) - Systems Generated

Choice 1: your

Choice 2: her

Choice 3: his

Fill-in (6) - Systems Generated

Choice 1: your

Choice 2: her

Choice 3: his

Fill-in (7) - Systems Generated

Choice 1: you pay your

Choice 2: he pays his

Choice 3: she pays her

HIB183 IRMAA – BENEFICIARY/PAYEE – PRIOR NOTICE RECEIVED EXPLAINING IRMAA (HB1)

(Requested/Generated)

Caption: Information About Medicare

We sent you another letter that explained how we determined the amount of  (1)  g premium.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

HIB184 ADVISES BENEFICIARY/PAYEE THAT WE WILL CONTINUE TO BILL FOR PART B PREMIUMS (HB4)

(Requested/Generated)

Caption: Information About Medicare

We will continue to bill  (1)  for  (2)  Medicare Part B premiums.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: him

Choice 2: her

Choice 3: you

Fill-in (2) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

HIB185 IRMAA – CMA ADJUSTED DUE TO CHANGE IN PART B PREMIUM AMOUNT (HB3)

(Requested/Generated)

Caption: Information About Medicare

The amount you will receive around  (1)  was changed because of a change in  (2)  monthly Medicare Part B premium.

Fill-in values:

Fill-in (1) - Requested As A Date in Format Shown Below

Choice 1: Using the PCI, show the calendar date in which the COM check will be paid

MM/DD/CCYY

Choice 2: Using the PCI, show the calendar date in which the DPD check will be paid

MM/DD/CCYY

Fill-in (2) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

HIB186 ADVISES ATTAINER/NEW FILER THAT IRMAA MAY APPLY BASED ON INCOME LEVEL (HB5)

(Requested/Generated)

Caption: Information About Medicare

IMPORTANT: A Medicare law requires some higher income persons to pay higher premiums. The law applies to premiums for Medicare Part B (medical insurance) and prescription drug coverage. The law generally affects individuals with incomes higher than  (1)  and couples with incomes higher than  (2)  . We will contact the Internal Revenue Service to get information about  (3)  income. If we decide that  (4)  to pay higher premiums, we will send a letter explaining our decision. The higher amount will be effective  (5)  g . For more information, please visit www.socialsecurity.gov on the Internet or call us toll-free at 1-800-772-1213 (TTY 1-800-325-0778).

Fill-in values:

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

Choice 1: Amount

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

Choice 1: Amount

Fill-in (3) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (4) - Systems Generated

Choice 1: he has

Choice 2: she has

Choice 3: you have

Fill-in (5) - Requested As A Date in Format Shown Below

Choice 1: SMI start Date MM/CCYY

HIB187 MEDICAL PREMIUM DEDUCTIONS CONTINUE (G24)

(System Generated)

Caption: Information About Medicare

We will continue to deduct Medicare premiums from  (1)  monthly checks.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's name possessive

HIB188 SMI REFUSAL (H01)

(Requested/Generated)

Caption: Your Benefits

 (1)  told us that  (2)  want medical insurance under Medicare. We will send  (3)  a new Medicare card in a few days. It will show that  (4)  g entitled to only hospital insurance.

We will stop taking premiums for medical insurance out of  (5)  checks. If we have taken out any premiums for months when  (6)  not entitled to medical insurance, we will return the money to  (7)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You

Choice 2: Beneficiary's Name

Fill-in (2) - Systems Generated

Choice 1: you do not

Choice 2: he does not

Choice 3: she does not

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (4) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (5) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (6) - Systems Generated

Choice 1: you were

Choice 2: he was

Choice 3: she was

Fill-in (7) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

HIB189 RAILROAD JURISDICTION (H02)

(Requested/Generated)

Caption: Information About Medicare

The Railroad Retirement Board is handling  (1)  hospital and medical insurance under Medicare.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's Name possessive

HIB190 REENTITLEMENT TO DIB - NEW 24 MONTH WAITING PERIOD NEEDED (H04)

(Requested)

Caption: Information About Medicare

Our records show that  (1)  had an earlier disability. The earlier disability is not the same as  (2)  disability now. Since the disabilities are different,  (3)  will need to wait 24 months for Medicare to begin. We will tell you in another letter when  (4)  can get Medicare.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's Name

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (4) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

HIB191 HI AND SMI DATE OF ENTITLEMENT (H11)

(Requested/Generated)

Caption: Information About Medicare

 (1)  entitled to hospital and medical insurance under Medicare beginning  (2)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You are

Choice 2: Beneficiary's Name is

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

Choice 1: MM/CCYY

HIB192 SUSPENSION OF 24 MONTH WAITING PERIOD - BENE DIAGNOSED WITH ALS (H16)

(Requested)

Caption: Information About Medicare

Because of a change in the law people receiving disability benefits because of Amyotrophic Lateral Sclerosis (ALS) no longer have to wait 24 months for Medicare coverage. We have therefore changed  (1)  entitlement dates to hospital insurance (Part A) and medical insurance (Part B) to  (2)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

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

Choice 1: MM/DD/CCYY

HIB193 SMI PREMIUM AMOUNTS AND EFFECTIVE DATES (H21)

(Requested/Generated)

Caption: Information About Medicare

We charge a monthly premium for  (1)  medical insurance. The rates are shown below:

Beginning Date Amount

 (2)   (3) 

NOTE: To allow multiple repetitions of the date and premium rates in Fill-ins 2 and 3, HIB259 is automatically generated.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

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

Choice 1: MM/CCYY

Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Amount of SMI premium

HIB194 STATE BUY-IN (H30)

(Requested/Generated)

Caption: Information About Medicare

The State where  (1)  will pay the premiums for  (2)  Medicare coverage beginning  (3)  .  (4)  may receive a refund for some of the premiums  (5)  may have paid, if the State is responsible for paying them.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you live

Choice 2: Beneficiary's Name lives

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

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

Choice 1: MM/CCYY

Fill-in (4) - Systems Generated

Choice 1: You

Choice 2: He

Choice 3: She

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

HIB195 PRIVATE GROUP BUY-IN (H32)

(Requested/Generated)

Caption: Information About Medicare

Beginning  (1)  , we will send the bills for  (2)  medical insurance premiums to the organization which  (3)  selected. Although we will send the bills to them,  (4)  will still be responsible for making sure that  (5)  premiums are paid. If the organization decides that it will no longer pay the premiums, we will start sending the premium bills to  (6)  again.

 (7)  may receive a refund for some of the premiums  (8)  g may have paid, if the organization is responsible for paying them.

Fill-in values:

Fill-in (1) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (3) - Systems Generated

Choice 1: you have

Choice 2: he has

Choice 3: she has

Fill-in (4) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (5) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (6) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (7) - Systems Generated

Choice 1: You

Choice 2: He

Choice 3: She

Fill-in (8) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

HIB196 TERMINATION OF PRIVATE GROUP BUY-IN (H40)

(Requested/Generated)

Caption: Information About Medicare

An organization has been paying  (1)  medical insurance premiums while  (2)  not receiving checks. Since we have started to pay  (3)  checks each month, we will take the premiums out of  (4)  checks beginning  (5)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (2) - Systems Generated

Choice 1: you were

Choice 2: he was

Choice 3: she was

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (5) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

HIB197 TERMINATION OF CIVIL SERVICE BUY-IN (H41)

(Requested/Generated)

Caption: Information About Medicare

 (1)  medical insurance premiums were taken out of  (2)  civil service annuity. Since we have started to pay  (3)  checks each month, we will take the premiums out of  (4)  Social Security checks beginning  (5)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Your

Choice 2: Beneficiary's Name possessive

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (5) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

HIB198 OPENING PARAGRAPH - AUXILIARY MQGE APPLICANT ON NUMBER HOLDER'S WAGE RECORD (H44)

(Requested)

Caption: None

This notice refers to  (1)  claim for  (2)  based on  (3)  Government employment.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (2) - Requested As A One Position Alpha Character

Choice 1: (A) Medicare

Choice 2: (B) Medicare as a disabled individual

Fill-in (3) - Systems Generated

Choice 1: Number Holder's name (possessive)

HIB199 BILLING FOR BOTH HI AND SMI PREMIUMS (H45)

(Requested)

Caption: Information About Medicare

The monthly premium for  (1)  medical insurance is  (2)  . The monthly premium for  (3)  hospital insurance is  (4)  . We will bill  (5)  each month for the combined premium for hospital and medical insurance.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (2) - Systems Generated

Choice 1: Amount of SMI premium

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (4) - Systems Generated

Choice 1: Amount of HI premium

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

HIB200 FULLY INSURED FOR MEDICARE AT AGE 65 (H47)

(Requested)

Caption: Information About Medicare

Based on  (1)  earnings and on the date of birth,  (2)  g worked long enough under Social Security to qualify for Medicare coverage at age 65.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name, possessive

Fill-in (2) - Systems Generated

Choice 1: you have

Choice 2: he has

Choice 3: she has

HIB212 HI START DATE PRIOR TO AGE 65 - HI AWARD ACTION TAKEN IN AGE 65 ATTAINMENT MONTH OR LATER (H48)

(Requested)

Caption: Information About Medicare

Now that  (1)  65 years old,  (2)  Medicare coverage is no longer based on  (3)  disability.  (4)  Medicare coverage does not change because  (5)  65. Work does not affect  (6)  Medicare eligibility. This is because work restrictions only apply to Medicare beneficiaries under age 65 and disabled. If  (7)  condition improves, and  (8)  to return to work, it is not necessary to notify Social Security.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you are

Choice 2: Beneficiary's Name is

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (4) - Systems Generated

Choice 1: Your

Choice 2: Beneficiary's Name possessive

Fill-in (5) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (6) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (7) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (8) - Systems Generated

Choice 1: you decide

Choice 2: he decides

Choice 3: she decides

HIB213 TOTALIZATION MONTHLY BENEFITS AWARDED TO U.S. RESIDENT BETWEEN AGE 50 AND AGE 64 AND 9 MONTHS. (NO MEDICARE ENTITLEMENT ON ANOTHER SSN) (H50)

(Requested)

Caption: Information About Medicare

If  (1)  to be entitled to Medicare insurance when  (2)  age 65,  (3)  will need to apply for it. The separate application is necessary because  (4)  monthly benefits are based on a combination of U.S. and foreign Social Security credits. Please get in touch with us 3 months before  (5)  65 for more information about Medicare insurance.  (6)  may have to pay for this insurance.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you wish

Choice 2: Beneficiary's Name wishes

Fill-in (2) - Systems Generated

Choice 1: you reach

Choice 2: he reaches

Choice 3: she reaches

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (5) - Systems Generated

Choice 1: you become

Choice 2: he becomes

Choice 3: she becomes

Fill-in (6) - Systems Generated

Choice 1: You

Choice 2: He

Choice 3: She

HIB214 TOTALIZATION MONTHLY BENEFITS AWARDED TO U.S. RESIDENT AT LEAST AGE 64 AND 9 MONTHS OR ALREADY ENTITLED TO DIB BENEFITS FOR 24 MONTHS — WORKER (NO FREE HI ENTITLEMENT ON ANOTHER SSN) (H51)

(Requested)

Caption: Information About Medicare

 (1)  not entitled to free Medicare hospital insurance under the Social Security agreement. We can use only U.S. Social Security credits to entitle someone to this insurance. This is true even though we have used foreign credits to pay monthly benefits.

 (2)  a total of  (3)  credits of work under the U.S. Social Security system to be entitled to free hospital insurance.  (4)   (5)  credits.  (6)   (7)  more credits to become entitled.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You are

Choice 2: Beneficiary's Name is

Fill-in (2) - Systems Generated

Choice 1: You need

Choice 2: He needs

Choice 3: She needs

Fill-in (3) – Requested As A Number

Choice 1: Number of quarters needed to be insured for HI

Fill-in (4) - Systems Generated

Choice 1: You have

Choice 2: He has

Choice 3: She has

Fill-in (5) – Requested As A Number

Choice 1: Number of quarters earned

Fill-in (6) - Systems Generated

Choice 1: You need

Choice 2: He needs

Choice 3: She needs

Fill-in (7) – Requested As A Number

Choice 1: Number of quarters needed

HIB215 HI AND SMI TERMINATION DUE TO DIB CESSATION AFTER 25TH MONTH (H82)

(Requested/Generated)

Caption: Information About Medicare

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-in values:

Fill-in (1) - Systems Generated

Choice 1: he is

Choice 2: she is

Choice 3: you are

Fill-in (2) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

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

Choice 1: (A) hospital

Choice 2: (B) hospital and medical

Fill-in (4) - Systems Generated

Choice 1: His

Choice 2: Her

Choice 3: Your

Fill-in (5) - Requested As A One Position Alpha Character

Choice 1: (A) hospital

Choice 2: (B) hospital and medical

Fill-in (6) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (7) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

HIB216 TOTALIZATION MONTHLY BENEFIT AWARDED TO U.S. RESIDENT AT LEAST AGE 64 AND 9 MONTHS OR ENTITLED TO DISABILITY BENEFITS FOR 24 MONTHS AUXILIARY OR SURVIVOR (NO FREE HI ENTITLEMENT ON ANOTHER SSN) (H52)

(Requested)

Caption: Information About Medicare

 (1)  not entitled to free Medicare hospital insurance under the Social Security agreement. We can use only U.S. Social Security credits to entitle someone to this insurance. This is true even though we have used foreign credits to pay monthly benefits.

For  (2)  to be entitled to free hospital insurance,  (3)  needed to have earned  (4)  credits of work under the U.S. system. However, only  (5)  g credits were earned.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You are

Choice 2: Beneficiary's Name is

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (3) - Requested As A Language

Choice 1: Name of worker

Fill-in (4) – Requested A Number

Choice 1: Number of quarters needed to be insured for HI

Fill-in (5) - Requested As A Number

Choice 1: Number of quarters earned

HIB217 INITIAL PREMIUM BILLING DUE TO ONE-CHECK-ONLY ADJUSTMENT PLUS SUSPENSION (H61)

(Requested/Generated)

Caption: Information About Medicare

We are taking medical insurance premiums out of the check  (1)  will receive. We will bill  (2)  every 3 months for future premiums, and will send  (3)  the bill shortly before payment is due.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

HIB218 FINAL PREMIUM ADJUSTMENT DUE TO TERMINATION OF BENEFITS (CAN BE USED FOR CONVERSION FROM T TO A.) (H62)

(Requested/Generated)

Caption: Information About Medicare

When we figured the amount of  (1)  payment, we took into account all medical insurance premiums which were already paid or still due.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

HIB219 PREMIUM ADJUSTMENT DUE TO DEFERRED ACTION THAT WILL MATURE IN CURRENT YEAR (H63)

(Requested/Generated)

Caption: Information About Medicare

We will change  (1)  next check to account for medical insurance premiums that are due or already paid.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

HIB220 INITIAL PREMIUM ADJUSTMENT DUE TO SMI ENTITLEMENT (H64)

(Requested/Generated)

Caption: Information About Medicare

We are taking medical insurance premiums due through  (1)  out of the check  (2)  will receive around  (3)  . These premiums total  (4)  . We will deduct medical insurance premiums 1 month in advance.

Fill-in values:

Fill-in (1) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's Name

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

Choice 1: MM/DD/CCYY

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

Choice 1: Amount of premiums

HIB221 PREMIUM ADJUSTMENT DUE TO CURRENT SMI ENTITLEMENT AND PRIOR PERIOD OF SMI ENTITLEMENT (H65)

(Requested/Generated)

Caption: Information About Medicare

We will  (1)  the payment  (2)  will receive shortly after  (3)  by  (4)  because of medical insurance premiums. When we figured the amount of  (5)  payment, we took into account all the medical insurance premiums which were previously paid or still due. We will deduct medical insurance premiums 1 month in advance.

Fill-in values:

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

Choice 1: (A) reduce

Choice 2: (B) increase

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's Name

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

Choice 1: MM/DD/CCYY

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

Choice 1: Amount (PDA)

Fill-in (5) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

HIB223 SUBSEQUENT PREMIUM AND PINQ RECORD ADJUSTMENT (H66)

(System Generated)

Caption: Information About Medicare

We will  (1)  the payment  (2)  will receive after  (3)  by  (4)  because of medical insurance premiums which were  (5)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: increase

Choice 2: reduce

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (3) - Systems Generated

Choice 1: MM/DD/CCYY

Fill-in (4) - Systems Generated

Choice 1: Amount (PDA)

Fill-in (5) - Requested As A One Position Alpha Character

Choice A: already paid

Choice B: owed

HIB224 PREMIUM AND PINQ RECORD ADJUSTMENT DUE TO RESUMPTION OF BENEFITS (H67)

(Requested/Generated)

Caption: Information About Medicare

We are  (1)   (2)  next payment by  (3)  because of the medical insurance premiums  (4)  . After that we will take premiums out of  (5)  regular checks each month.

Fill-in values:

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

Choice 1: (A) reducing

Choice 2: (B) increasing

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (3) - Requested As A Money Amount in Format $$$$$.¢¢

Choice 1: Amount

Fill-in (4) - Requested As A One Position Alpha Character

Choice 1: (A) you owe

Choice 2: (B) he owes

Choice 3: (C) she owes

Choice 4: (D) already paid

Fill-in (5) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

HIB228 SMI PREMIUM CHANGED TO VARIABLE RATE DUE TO DELAYED DECEMBER COM PROCESSING (H72)

(Requested)

Caption: Information About Medicare

We have determined that the premium amount of  (1)  , which  (2)  now being charged, should be reduced to  (3)  effective with January of this year. This reduction in  (4)  premium is being made because the increase in  (5)  premium as of January 1st resulted in a decrease in  (6)  monthly Social Security check. The law permits us to reduce the Part B premium amount as necessary (but not below the amount  (7)  paid in December of last year) if the yearly change in the premium would cause the Social Security checks  (8)  this year to be lower than the checks  (9)  last year.

Fill-in values:

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

Choice 1: SMI premium rate

Fill-in (2) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: New variable SMI rate

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (5) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (6) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (7) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (8) - Systems Generated

Choice 1: you receive

Choice 2: he receives

Choice 3: she receives

Fill-in (9) - Systems Generated

Choice 1: you received

Choice 2: he received

Choice 3: she received

HIB229 REVIEW REQUESTED VARIABLE SMI PREMIUM APPLIES (H73)

(Requested)

Caption: Information About Medicare

As  (1)  requested, we reviewed the amount of the premium  (2)  each month for medical insurance. We've decided that  (3)  premium should have been  (4)  since January  (5) . Because we've been charging  (6)   (7)  , it caused  (8)  to get less money in  (9)  Social Security check. This is why we'll lower  (10)  premium.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's Name

Fill-in (2) - Systems Generated

Choice 1: you pay

Choice 2: he pays

Choice 3: she pays

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

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

Choice 1: Variable premium for SMI, plus surcharge amount

Fill-in (5) - Requested As A Date In Format Shown Below

Choice 1: CCYY

Fill-in (6) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (7) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Current base premium for SMI, plus surcharge, if applicable

Fill-in (8) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (9) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (10) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

HIB231 ERRONEOUS SMI TERMINATION EQUITABLE RELIEF GIVEN (H75)

(Requested)

Caption: Information About Medicare

We stopped  (1)  Medical insurance coverage under Medicare in  (2)  by mistake. We are sorry if our error caused  (3)  any inconvenience. We have corrected the mistake, and are starting  (4)  coverage again beginning  (5)  .

It might be to  (6)  advantage to start  (7)  medical coverage at an earlier date. We can start the coverage beginning  (8)  . However,  (9)  would have to pay the premiums for this insurance. The total amount of premiums from  (10)  through  (11)  is  (12)  .

If  (13)  coverage to start at the earlier date, please let us know within 60 days.  (14)  will need to tell us whether  (15)  to pay us directly for the premiums or have us take the money for the premiums out of  (16)  checks.

If  (17)  would like to have coverage beginning  (18)  , but it would be a hardship for  (19)  g to pay the premiums at one time, please let us know.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

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

Choice 1: MM/CCYY

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (5) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (6) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name, possessive

Fill-in (7) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (8) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (9) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (10) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (11) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (12) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Premium amount due

Fill-in (13) - Systems Generated

Choice 1: you want

Choice 2: he wants

Choice 3: she wants

Fill-in (14) - Systems Generated

Choice 1: You

Choice 2: He

Choice 3: She

Fill-in (15) - Systems Generated

Choice 1: you want

Choice 2: he wants

Choice 3: she wants

Fill-in (16) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (17) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (18) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (19) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

HIB232 PART B PREMIUM SURCHARGE ROLLBACK (H78)

(Requested)

Caption: Information About Medicare

We reduced the premium  (1)  paying for  (2)  medical insurance under Medicare. This is because of  (3)  health insurance coverage under an employer's health plan.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

HIB233 PART B ENROLLEE BENEFITS SUSPENDED FOR WORK (H79)

(Requested)

Caption: Information About Medicare

 (1)  not getting benefits because  (2)  working, so  (3)  to know some special facts about Medicare.  (4)  to consider these facts if  (5)  working for an employer who has 20 or more employees:

  • If  (6)  covered under  (7)  employer's group health plan, it will pay first for  (8)  g health care needs.

  • Medicare will not pay any expenses that the group health plan pays for.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You are

Choice 2: Beneficiary's Name is

Fill-in (2) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (3) - Systems Generated

Choice 1: you need

Choice 2: he needs

Choice 3: she needs

Fill-in (4) - Systems Generated

Choice 1: You only need

Choice 2: He only needs

Choice 3: She only needs

Fill-in (5) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (6) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (7) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (8) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

HIB234 SMI WITHDRAWAL (H81)

(Requested/Generated)

Caption: Information About Medicare

 (1)  asked that we stop  (2)  medical insurance coverage under Medicare. This coverage ends the last day of  (3)  . If  (4)  g hospital insurance coverage, it will continue.

 (5) 

If  (6)  in the future that  (7)  would like to have medical insurance coverage again, please get in touch with us.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You

Choice 2: Beneficiary's Name

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

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

Choice 1: MM/CCYY

Fill-in (4) - Systems Generated

Choice 1: you have

Choice 2: he has

Choice 3: she has

Fill-in (5) - Requested As A One Position Alpha Character

Choice 1: (A) We will stop taking premiums out of your Social Security checks. We will change your next payment to account for any premiums still due or any which you have already paid.

Choice 2: (B) Null

Fill-in (6) - Systems Generated

Choice 1: you decide

Choice 2: he decides

Choice 3: she decides

Fill-in (7) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

HIB235 INELIGIBLE FOR HI/SMI DIB CESSATION PRIOR TO 25TH MONTH (H83)

(System Generated)

Caption: Information About Medicare

Since  (1)  no longer entitled to monthly Social Security benefits,  (2)  will not be eligible for Medicare insurance. Please disregard any information we may have given  (3)  about Medicare.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you are

Choice 2: Beneficiary's Name is

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

HIB236 PREMIUM ADJUSTMENT DUE TO SMI TERMINATION (H85)

(Requested/Generated)

Caption: Information About Medicare

Because we stopped  (1)  medical insurance, under Medicare, we will change the payment  (2)  will receive around  (3)  by  (4)  to account for premiums which were  (5)  g .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

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

Choice 1: MM/DD/CCYY

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

Choice 1: Money amount

Fill-in (5) - Requested As A One Position Alpha Character

Choice 1: (A) still due

Choice 2: (B) already paid

HIB237 DISABILITY CESSATION PREMIUMS DUE FOR FUTURE MONTH(S) (H86)

(Requested/Generated)

Caption: Information About Medicare

Premiums for medical insurance under Medicare are paid 1 month in advance. Since you have only paid  (1)  premiums through  (2) , you owe  (3)  to pay for the remaining premiums.

Please make your check or money order payable to the “Centers for Medicare & Medicaid Services”. Include  (4)  Medicare number on your check or money order. Send your payment to:

Centers for Medicare & Medicaid Services
Medicare Premium Collection Center
PO BOX 790355
St. Louis, MO 63179-0355

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary's Name possessive

Choice 2: your

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

Choice 1: MM/CCYY

Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Money amount

Fill-in (4) - Systems Generated

Choice 1: Beneficiary's Name possessive

Choice 2: your

HIB238 INTRODUCTORY UTI FOR HEALTH PLAN PREMIUMS AND MEDICARE PRESCRIPTION DRUG PLAN COSTS (H88)

(Requested/Generated)

Caption: Information About Health Plan Premiums And Prescription Drug Plan Costs

As  (1)  requested, we will begin deducting  (2)  health plan premiums and Medicare prescription drug plan costs from  (3)  monthly benefit.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary's full name

Choice 2: you

Fill-in (2) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (3) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

HIB239 CRD ENTITLEMENT MONTHLY BENEFITS TERMINATED HI ENTITLEMENT CONTINUES (H92)

(Requested/Generated)

Caption: Information About Medicare

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

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you are

Choice 2: Beneficiary's name is

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's name, possessive

HIB240 ADDRESS CHANGED TO FOREIGN COUNTRY ENTITLED TO HI ONLY (H95)

(Requested)

Caption: Information About Medicare

In most cases, Medicare will only pay for hospital services which  (1)  in the United States. Since  (2)  living outside the U.S., Medicare will not pay for hospital services unless  (3)  to the U.S. for services.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you receive

Choice 2: Beneficiary's Name receives

Fill-in (2) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (3) - Systems Generated

Choice 1: you return

Choice 2: he returns

Choice 3: she returns

HIB241 FOREIGN ADDRESS GENERAL MEDICARE ELIGIBILITY (H96)

(Requested)

Caption: Information About Medicare

In most cases, Medicare will only pay for hospital and medical services which  (1)  in the United States.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you receive

Choice 2: Beneficiary's Name receives

HIB242 AUXILIARY BENEFICIARY AGE 65 OR OVER TERMINATED T3, T8 OR T9 NEW HEALTH INSURANCE CARD SMI ONLY (H98)

(Requested/Generated)

Caption: Information About Medicare

Even though  (1)  no longer receiving monthly checks and  (2)  not have hospital insurance coverage under Medicare,  (3)  will still have medical insurance coverage. We will send  (4)  a new Medicare card, which will show that  (5)  medical insurance only.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you are

Choice 2: Beneficiary's name is

Fill-in (2) - Systems Generated

Choice 1: do

Choice 2: does

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (4) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (5) - Systems Generated

Choice 1: you now have

Choice 2: he now has

Choice 3: she now has

HIB243 3RD PARTY BUY-IN FOR AUXILIARY BENEFICIARY AGE 65 OR OVER TERMINATED T3, T8 or T9 (H99)

(Requested/Generated)

Caption: Information About Medicare

We charge monthly premiums for  (1)  medical insurance under Medicare.  (2)  will continue to pay these premiums.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (2) - Requested As A One Position Alpha Character

Choice 1: (A) The State where you live

Choice 2: (B) The organization you choose

HIB244 DIB CESSATION OVERPAYMENT AND PREMIUMS DUE FOR A FUTURE MONTH (H87)

(Requested/Generated)

Caption: Information About Medicare

 (1)  overpayment includes the Medicare medical insurance premiums of  (2)  which we took out of  (3)  checks during the time when  (4)  overpaid. Also,  (5)  not paid  (6)  premiums for  (7)  . For this reason, when  (8)  back  (9)  overpayment  (10)  should include  (11)  to pay for all premiums due.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Your

Choice 2: Beneficiary's Name possessive

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

Choice 1: Amount

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (4) - Systems Generated

Choice 1: you were

Choice 2: he was

Choice 3: she was

Fill-in (5) - Systems Generated

Choice 1: you have

Choice 2: he has

Choice 3: she has

Fill-in (6) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (7) - Requested As A Date In Format Shown Below

Choice 1: MMCCYY

Fill-in (8) - Systems Generated

Choice 1: you pay

Choice 2: he pays

Choice 3: she pays

Fill-in (9) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (10) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (11) - Requested As A Money Amount in Format $$$$$.¢¢

Choice 1: Amount

HIB249 EQUITABLE RELIEF FOR V-SMI CASES ONLY (HC2)

(Requested/Generated)

Caption: Information About Medicare

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)  g ;

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-in values:

Fill-in (1) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

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

Choice 1: MM/CCYY

Fill-in (3) - Requested As A Money Amount in Format $$$$$.¢¢

Choice 1: Amount

Fill-in (4) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (5) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (6) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (7) - Requested As A Money Amount in Format $$$$$.¢¢

Choice 1: Amount

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

Choice 1: Amount

HIB250 CHANGE IN RESIDENCE AFFECTS PREMIUM AMOUNT CATASTROPHIC LEGISLATION (H76)

(System Generated)

Caption: Information About Medicare

Beginning  (1)  we are changing  (2)  monthly Medicare premium rate to  (3)  because of  (4)  change in residence.

Fill-in values:

Fill-in (1) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Premium Amount

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

HIB251 WORK REINSTATEMENT NO SMI (H77)

(Requested)

Caption: Information About Medicare

 (1)  getting benefits because  (2)  stopped working, so  (3)  to know some special facts about Medicare.  (4)  to consider these facts if  (5)  covered under an employer group health plan while  (6)  working:

  1.  (7)  may enroll for medical insurance under Medicare up until 8 months after  (8)  working.

  2. If  (9)  for medical insurance during the 8 months,  (10)  coverage will start sooner than if  (11)  until the regular enrollment time of January through March.

  3. Also,  (12)  may have to pay a premium penalty if  (13)  a full 12 months when  (14)  could have been, but  (15)  not, covered by Medicare. We do not count months of employer group health plan coverage when figuring the 12-month period.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You are

Choice 2: Beneficiary name is

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (3) - Systems Generated

Choice 1: you need

Choice 2: he needs

Choice 3: she needs

Fill-in (4) - Systems Generated

Choice 1: You only need

Choice 2: He only needs

Choice 3: She only needs

Fill-in (5) - Systems Generated

Choice 1: you were

Choice 2: he was

Choice 3: she was

Fill-in (6) - Systems Generated

Choice 1: you were

Choice 2: he was

Choice 3: she was

Fill-in (7) - Systems Generated

Choice 1: You

Choice 2: He

Choice 3: She

Fill-in (8) - Systems Generated

Choice 1: you stop

Choice 2: he stops

Choice 3: she stops

Fill-in (9) - Systems Generated

Choice 1: you enroll

Choice 2: he enrolls

Choice 3: she enrolls

Fill-in (10) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (11) - Systems Generated

Choice 1: you wait

Choice 2: he waits

Choice 3: she waits

Fill-in (12) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (13) - Systems Generated

Choice 1: you have

Choice 2: he has

Choice 3: she has

Fill-in (14) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (15) - Systems Generated

Choice 1: were

Choice 2: was

HIB252 EQUITABLE RELIEF UNTIMELY PROCESSING (H49)

(Requested/Generated)

Caption: Information About Medicare

We did not give  (1)  earlier medical insurance because we did not process it timely. If  (2)  to have these benefits earlier,  (3)  can choose medical insurance benefits beginning  (4)  . If  (5)  this benefit to start earlier,  (6)  must do the following things within 60 days after the date of this notice:

  • tell us in writing that  (7)  the medical insurance benefits beginning  (8)  ;

  • pay us  (9)  (this covers the premiums due from  (10)  through  (11)  ); or,

  • tell us we can withhold this amount from the check.

If  (12)  the benefits beginning  (13)  but  (14)  it hard to pay the premium amount in a lump sum, ask us about other ways to pay the money.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary name

Choice 2: you

Fill-in (2) - Systems Generated

Choice 1: you want

Choice 2: he wants

Choice 3: she wants

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (4) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (5) - Systems Generated

Choice 1: you want

Choice 2: he wants

Choice 3: she wants

Fill-in (6) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (7) - Systems Generated

Choice 1: you want

Choice 2: he wants

Choice 3: she wants

Fill-in (8) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (9) - Requested As A Money Amount in Format $$$$$.¢¢

Choice 1: Total amount of medical insurance premiums

Fill-in (10) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (11) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (12) - Systems Generated

Choice 1: you want

Choice 2: he wants

Choice 3: she wants

Fill-in (13) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (14) - Systems Generated

Choice 1: find

Choice 2: finds

HIB254 CHANGE IN DATE OF ENTITLEMENT TO HI AND SMI (H14)

(Requested/Generated)

Caption: Information About Medicare

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

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (2) - Systems Generated

Choice 1: Your

Choice 2: His

Choice 3: Her

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

Choice 1: MM/CCYY

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

HIB255 CHANGE IN DATE OF ENTITLEMENT TO HI (H15)

(Requested/Generated)

Caption: Information About Medicare

We have changed the date of  (1)  entitlement to hospital insurance under Medicare.  (2)  new entitlement date is  (3)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (2) - Systems Generated

Choice 1: Your

Choice 2: His

Choice 3: Her

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

Choice 1: MM/CCYY

HIB256 FUTURE MEDICARE COVERAGE (H07)

(Requested/Generated)

Caption: Information About Medicare

 (1)  may be able to buy Medicare coverage in the future. If  (2)  a citizen of the United States,  (3)  can buy Medicare as soon as  (4)  to this country. If  (5)  not a citizen,  (6)  can buy Medicare only after  (7)  lived in the United States for five years in a row. These must be the five years right before  (8)  for Medicare. Also, as an alien  (9)  must be lawfully admitted for permanent residence.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You

Choice 2: Beneficiary's name

Fill-in (2) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (4) - Systems Generated

Choice 1: you return

Choice 2: he returns

Choice 3: she returns

Fill-in (5) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (6) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (7) - Systems Generated

Choice 1: you have

Choice 2: he has

Choice 3: she has

Fill-in (8) - Systems Generated

Choice 1: you apply

Choice 2: he applies

Choice 3: she

Fill-in (9) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

HIB257 WHAT HOSPITAL INSURANCE WILL PAY (H27)

(Requested/Generated)

Caption: Information About Medicare

Hospital insurance will pay most hospital bills and certain post-hospital expenses. Medical insurance will help pay much of the medical expenses incurred for physicians and other medical services. This notice shows whether  (1)  entitled to hospital insurance only, medical insurance only, or both hospital and medical insurance. Benefits are payable if covered services were rendered on or after the entitlement date shown.  (2)  will receive by mail a health insurance card and a booklet explaining how to use the card, what services are covered, and the methods of claiming benefits for covered services. If  (3)  planning changes in any other hospital or medical insurance  (4)  , remember that Social Security health insurance coverage will be effective with the dates shown on this notice.

If  (5)  help with medical expenses before  (6)  health insurance coverage begins, or if  (7)  aid in meeting medical expenses not covered by  (8)  health insurance,  (9)  may want to get in touch with the nearest social services office to see whether  (10)  eligible under a program of medical assistance.

Notify any Social Security office immediately if  (11)   (12)  address so that  (13)  health insurance card and any claims or informational material may reach  (14)  promptly.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you are

Choice 2: Beneficiary's name + is

Fill-in (2) - Systems Generated

Choice 1: You

Choice 2: He

Choice 3: She

Fill-in (3) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (4) - Systems Generated

Choice 1: you now have

Choice 2: he now has

Choice 3: she now has

Fill-in (5) - Systems Generated

Choice 1: you need

Choice 2: he needs

Choice 3: she needs

Fill-in (6) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (7) - Systems Generated

Choice 1: you need

Choice 2: he needs

Choice 3: she needs

Fill-in (8) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (9) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (10) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (11) - Systems Generated

Choice 1: you change

Choice 2: he changes

Choice 3: she changes

Fill-in (12) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (13) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (14) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

HIB258 OPENING INTRO WHEN BENEFICIARY IS ENTITLED TO MEDICARE BENEFITS UNDER TITLE XVIII

(Requested/Generated)

Caption: None

This certifies that  (1)  entitled under Title XVIII of the Social Security Act to the Medicare benefits shown, beginning with the date indicated.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you are

Choice 2: Beneficiary's name + is

HIB259 SMI PREMIUM AMOUNTS AND EFFECTIVE DATES (H21 DETAIL LINE)

(Systems Generated)

Caption: Information About Medicare

 (1)   (2) 

NOTE: This UTI is automatically generated whenever HIB193 is requested/generated and there is more than one row of data to display in Fill-ins two and three under the headers in the chart.

Fill-in values:

Fill-in (1) - Systems Generated As A Date In Format Shown Below

Choice 1: MM/CCYY

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

Choice 1: Amount of SMI premium

HIB260 IRMAA

(System Generated)

Caption: Information About Medicare

As we told you in another letter, you owe more Medicare premiums because  (1)  income-related monthly adjustment amounts changed.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Name possessive

Choice 2: your

HIB261 IRMAA

(System Generated)

Caption: Information About Medicare

You owe  (1)  for Medicare Part B (medical insurance) premiums for  (2)   (3)   (4)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Total Amount in $$$$$¢¢ format

Fill-in (2) - Systems Generated

Choice 1: MM/CCYY

Fill-in (3) - Systems Generated

Choice 1: null

Choice 2: and

Choice 3: through

Fill-in (4) - Systems Generated

Choice 1: null

Choice 2: MM/CCYY

HIB262 IRMAA D

(System Generated)

Caption: Information About Medicare

You owe  (1)  for Medicare prescription drug coverage income-related monthly adjustment amounts for  (2)   (3)   (4)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Total Amount in $$$$$¢¢ format

Fill-in (2) - Systems Generated

Choice 1: MM/CCYY

Fill-in (3) - Systems Generated

Choice 1: null

Choice 2: and

Choice 3: through

Fill-in (4) - Systems Generated

Choice 1: null

Choice 2: MM/CCYY

HIB263 IRMAA B and D

(System Generated)

Caption: Information About Medicare

The total past-due Medicare amounts you owe are  (1)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Total Amount in $$$$$¢¢ format

HIB264 IRMAA Waiver Request

(System Generated)

Caption: Information About Medicare

If you would find it hard to pay the past-due Medicare amounts  (1)  at one time, please ask us about other ways to pay them. You may ask for waiver of these past-due Medicare amounts if paying them would be a severe financial hardship for you. If we do not hear from you within 30 days after the date of this letter, we will take the Medicare amounts  (2)  out of  (3)  monthly Social Security payments beginning  (4)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: he owes

Choice 2: she owes

Choice 3: you owe

Fill-in (2) - Systems Generated

Choice 1: he owes

Choice 2: she owes

Choice 3: you owe

Fill-in (3) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (4) - Systems Generated

Choice 1: MM/CCYY (COM + 2 months)

HIB265 IRMAA Deduction

(System Generated)

Caption: Information About Medicare

We will deduct  (1)  current Medicare Part B (medical insurance) premium from  (2)  monthly Social Security payments beginning  (3)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Name possessive

Choice 2: your

Fill-in (2) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (3) - Systems Generated

Choice 1: MM/CCYY (COM)

HIB266 IRMAA B Deduction

(System Generated)

Caption: Information About Medicare

We will also deduct  (1)  for past-due Medicare Part B (medical insurance) premiums.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Amount in $$$$$¢¢ format

HIB267 IRMAA D Deduction

(System Generated)

Caption: Information About Medicare

We will also deduct  (1)  for past-due Medicare prescription drug coverage income-related monthly adjustment amounts.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Amount in $$$$$¢¢ format

HIB268 IRMAA Partial Recovery

(System Generated)

Caption: Information About Medicare

We will deduct past-due Medicare prescription drug coverage income-related monthly adjustment amounts from your monthly Social Security payments beginning  (1)  . The total amount we will deduct is  (2)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: MM/CCYY (COM)

Fill-in (2) - Systems Generated

Choice 1: Amount in $$$$$¢¢ format

HIB269 IRMAA Total Withholding

(System Generated)

Caption: Information About Medicare

We will withhold  (1)  monthly payments until you have paid all of the past-due Medicare amounts  (2)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Name possessive

Choice 2: your

Fill-in (2) - Systems Generated

Choice 1: he owes

Choice 2: she owes

Choice 3: you owe

HIB270 IRMAA PART B Arrearage

(System Generated)

Caption: Information About Medicare

We will deduct past due Medicare Part B (medical insurance) premiums from your monthly Social Security payments beginning  (1)  . The total amount we will deduct is  (2)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: MM/CCYY (COM)

Fill-in (2) - Systems Generated

Choice 1: Amount in $$$$$.¢¢ format

HIB271 IRMAA D and/or B Installment Payment

(System Generated)

Caption: Information About Your Installment Payment

As you requested, we will withhold  (1)  from  (2)  monthly Social Security payments beginning  (3)  for past due Medicare amounts owed. We will withhold  (4)  each month until you have paid all of the past due Medicare amounts you owe.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Amount in $$$$$.¢¢ format

Fill-in (2) - Systems Generated

Choice 1: Name possessive

Choice 2: your

Fill-in (3) - Systems Generated

Choice 1: MM/CCYY (COM)

Fill-in (4) - Systems Generated

Choice 1: Amount in $$$$$.¢¢ format

HIBR60 MEDICAL INSURANCE INFORMATION PRIMARY IS IMPRISONED OR CONFINED (H03)

(Requested)

Caption: Information About Medicare

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-in values:

Fill-in (1) - Systems Generated

Choice 1: you receive

Choice 2: Beneficiary's Name receives

Fill-in (2) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

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

Choice 1: (A) imprisoned

Choice 2: (B) confined in a institution

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (5) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (6) - Systems Generated

Choice 1: prison

Choice 2: the institution

Fill-in (7) - Systems Generated

Choice 1: You

Choice 2: He

Choice 3: She

Fill-in (8) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (9) - Systems Generated

Choice 1: prison

Choice 2: the institution

Fill-in (10) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (11) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

NL 00720.220 MOE Month of Entitlement

MOE003 MONTH OF ENTITLEMENT CHANGE — ELECTION BEFORE FULL RETIREMENT AGE (A50)

(Requested)

Caption: Your Benefits

We reviewed  (1)  record. When  (2)  applied for benefits,  (3)  asked us to start  (4)  benefits in  (5)  . We changed the month  (6)  benefits start to  (7)  because of  (8)   (9)  work and earnings.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary's Name possessive

Choice 2: your

Fill-in (2) - Systems Generated

Choice 1: he

Choice 2: she

Choice 3: you

Fill-in (3) - Systems Generated

Choice 1: he

Choice 2: she

Choice 3: you

Fill-in (4) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (5) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (6) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (7) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (8) - Systems Generated

Choice 1: you

Choice 2: his

Choice 3: her

Fill-in (9) - Requested As A Date In Format Shown Below

Choice 1: CCYY

MOE004 MONTH OF ENTITLEMENT CHANGE - WORK AND EARNINGS UPDATE - DUAL ENTITLEMENT INVOLVED

(Requested)

Caption: None If Used As An Intro; or Caption: Based On Your Expected Earnings

We reviewed  (1)  record. When  (2)  applied,  (3)  asked us to start  (4)  benefits in  (5)  . We changed the month  (6)  benefits start to  (7)  because of  (8)   (9)  work and earnings.

 (10)  also receiving benefits on another record. We will send you another letter about those benefits.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary's Name possessive

Choice 2: your

Fill-in (2) - Systems Generated

Choice 1: he

Choice 2: she

Choice 3: you

Fill-in (3) - Systems Generated

Choice 1: he

Choice 2: she

Choice 3: you

Fill-in (4) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (5) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (6) - Systems Generated

Choice 1: Beneficiary's Name possessive

Choice 2: your

Fill-in (7) - Requested As A Date In Format Shown Below

Choice 1: MM/ CCYY

Fill-in (8) - Systems Generated

Choice 1: Beneficiary's Name possessive

Choice 2: Number Holder's Name possessive

Choice 3: your

Fill-in (9) - Requested As A Date In Format Shown Below

Choice 1: CCYY

Fill-in (10) - Systems Generated

Choice 1: He is

Choice 2: She is

Choice 3: You are

MOE005 EARLY MONTH OF ENTITLEMENT DUE TO WORK AND EARNINGS – NO REDUCTION IN BENEFITS – DUALLY ENTITLED

(Requested)

Caption: None If Used As An Intro; or Caption: Based On Your Expected Earnings

We reviewed  (1)  record. When  (2)  applied,  (3)  asked us to start  (4)  benefits in  (5)  . We changed the month  (6)  benefits start to  (7)  because of  (8)   (9)  work and earnings. The change lets  (10)  get payments without permanently reducing  (11)  monthly benefits.

 (12)  also receiving benefits on another record. We will send you another letter about those benefits.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary's Name possessive

Choice 2: your

Fill-in (2) - Systems Generated

Choice 1: he

Choice 2: she

Choice 3: you

Fill-in (3) - Systems Generated

Choice 1: he

Choice 2: she

Choice 3: you

Fill-in (4) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (5) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (6) - Systems Generated

Choice 1: Beneficiary's Name possessive

Choice 2: your

Fill-in (7) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (8) - Systems Generated

Choice 1: Beneficiary's Name possessive

Choice 2: Number Holder's Name possessive

Choice 3: your

Fill-in (9) - Requested As A Date In Format Shown Below

Choice 1: CCYY

Choice 2: CCYY and CCYY

Fill-in (10) - Systems Generated

Choice 1: him

Choice 2: her

Choice 3: you

Fill-in (11) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (12) - Systems Generated

Choice 1: He is

Choice 2: She is

Choice 3: You are

MOE006 MONTH OF ENTITLEMENT – WORK AND EARNINGS CHANGED ON DUAL ENTITLEMENT RECORD

(Requested)

Caption: None If Used As An Intro; or Caption: Based On Your Expected Earnings

We changed the month  (1)  benefits start on  (2)  record from  (3)  to  (4)  . We changed the month because of  (5)   (6)  work and earnings.  (7)  is the earliest month  (8)  can get benefits on  (9)  record.  (10)  benefits must start before  (11)  benefits can start.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary's Name possessive

Choice 2: your

Fill-in (2) - Systems Generated

Choice 1: Beneficiary's Name possessive (Primary on other record)

Fill-in (3) - Systems Generated

Choice 1: MM/CCYY

Fill-in (4) - Systems Generated

Choice 1: MM/CCYY

Fill-in (5) - Systems Generated

Choice 1: Beneficiary's Name possessive

Choice 2: Number Holders Name possessive

Choice 3: your

Fill-in (6) - Requested As A Date In Format Shown Below

Choice 1: CCYY

Fill-in (7) - Systems Generated

Choice 1: MM/CCYY

Fill-in (8) - Systems Generated

Choice 1: Beneficiary's Name

Choice 2: you

Fill-in (9) - Systems Generated

Number Holders Name possessive

Fill-in (10) - Systems Generated

Number Holders Name possessive

Fill-in (11) - Systems Generated

Choice 1: Beneficiary's Name possessive

Choice 2: your

MOE007 MONTH OF ENTITLEMENT CHANGE – NO REDUCING OF BENEFITS

(Requested)

Caption: None If Used As An Intro; or Caption: Based On Your Expected Earnings

We reviewed  (1)  record. When  (2)  applied,  (3)  asked us to start  (4)  benefits in  (5)  . We changed the month  (6)  benefits start to  (7)  because of  (8)   (9)  work and earnings. This change lets  (10)  get payments without permanently reducing  (11)  monthly benefits.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary's Name possessive

Choice 2: your

Fill-in (2) - Systems Generated

Choice 1: he

Choice 2: she

Choice 3: you

Fill-in (3) - Systems Generated

Choice 1: he

Choice 2: she

Choice 3: you

Fill-in (4) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (5) - Systems Generated

Choice 1: MM/CCYY

Fill-in (6) - Systems Generated

Choice 1: Beneficiary's Name possessive

Choice 2: your

Fill-in (7) - Systems Generated

Choice 1: MM/CCYY

Fill-in (8) - Systems Generated

Choice 1: Beneficiary's Name possessive

Choice 2: Number Holders Name possessive

Choice 3: your

Fill-in (9) - Requested As A Date In Format Shown Below

Choice 1: CCYY

Choice 2: CCYY and CCYY

Fill-in (10) - Systems Generated

Choice 1: him

Choice 2: her

Choice 2: you

Fill-in (11) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

MOE008 EARLIER MONTH OF ENTITLEMENT

(Generated/Requested)

Caption: Your Benefits

We have reviewed  (1)  record. When  (2)  applied,  (3)  asked us to start  (4)  benefits in  (5)  . We changed the month  (6)  benefits start to  (7)  due to  (8)   (9)  work and earnings.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (5) - Systems Generated or Requested As A Date

DOEC-MM/YYYY

Fill-in (6) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (7) - Systems Generated

Adjusted MOEL — MM/YYYY

Fill-in (8) - Systems Generated

Choice 1: your

Choice 2: Working NH's first and last name possessive

Fill-in (9) - Systems Generated

Enforcement year — YYYY

NL 00720.245 OPT Overpayment

OPT028 NEW OVERPAYMENT AMOUNT INCLUDES PRIOR OVERPAYMENT (M05)

(Requested)

Caption: Your Benefits

However, the total overpayment is  (1)  , which includes a prior overpayment of  (2)  .

Fill-in values:

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

Total overpayment

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

Current balance of prior overpayment

OPT107 OVERPAYMENT RECOVERED FROM ONE MONTH'S BENEFIT (A57)

(Requested)

Caption: Your Benefits

We will withhold  (1)   (2)   (3)   (4)  payment to recover the money we  (5)   (6)  . This is the payment you would normally receive about  (7)  .

Fill-in values:

Fill-in (1) – Systems Generated

Choice 1: null

Fill-in (2) – Systems Generated

Choice 1: null

Fill-in (3) – Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Choice 4: Beneficiary's name

Fill-in (4) – Systems Generated

month and year (MM/CCYY)

Fill-in (5) – Systems Generated

Choice 1: overpaid

Choice 2: incorrectly paid

Fill-in (6) – Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Choice 4: Beneficiary's name

Fill-in (7) – Systems Generated

month and year (MM/CCYY)

OPT122 BENEFICIARY OVERPAID DUE TO SUSPENSION/TERMINATION (M13)

(Requested)

Caption: Your Benefits

Since we did not stop  (1)  payments until  (2)  ,  (3)  paid  (4)  too much in benefits.

Fill-in values:

Fill-in (1) – Systems Generated

Choice 1: Beneficiary's Name (possessive)

Choice 2: your

Fill-in (2) – Systems Generated

MM/CCYY

Fill-in (3) – Systems Generated

Choice 1: he was

Choice 2: she was

Choice 3: you were

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

Choice 1: Amount of overpayment

OPT127 UNDERPAYMENT USED TO REDUCE/RECOVER AN OVERPAYMENT (M03)

(Requested)

Caption: Your Benefits

We used  (1)  of  (2)  benefits to recover  (3)  of an overpayment on this record.

Fill-in values:

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

Amount used for recovery

Fill-in (2) - Requested As A One Position Alpha Character or Language

Choice 1: (A) your

Choice 2: Name of Beneficiary

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

Choice 1: (A) all

Choice 2: (B) part

OPT132 DIRECT DEPOSIT — JOINT ACCOUNT — RECOVERY OF PAYMENTS MADE AFTER DEATH (A16)

(Requested)

Caption: Your Benefits

We paid  (1)  more in benefits than we should have. We deposited  (2)  benefits for  (3)  into a bank account which  (4)  also owned. We can't pay benefits for the month of death,  (5)  , or later. Because  (6)  a joint owner of the bank account,  (7)  overpaid  (8)  .

Fill-in values:

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

Amount of overpayment

Fill-in (2) Requested

Full name of the deceased beneficiary, possessive

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

Month(s) and year(s) of incorrect payment

Choice 1: MM/CCYY

Choice 2: MM/CCYY through MM/CCYY

Fill-in (4) Systems Generated

Choice 1: you

Choice 2: Beneficiary's first name

Fill-in (5) Requested

Month(s) and year(s) of incorrect payment

Choice 1: MM/CCYY

Choice 2: MM/CCYY through MM/CCYY

Fill-in (6) Systems Generated

Choice 1: Beneficiary's name is

Choice 2: you are

Fill-in (7) Systems Generated

Choice 1: Beneficiary's name is

Choice 2: you are

Fill-in (8) Requested

Amount of overpayment

OPT148 CROSS PROGRAM RECOVERY - T16 UNDERPAYMENT USED TO RECOVER T2 OVERPAYMENT (B88)

(System Generated)

Caption: Your Benefits

We used  (1)  of  (2)  SSI benefits to recover some or all of an overpayment on this record.

Fill-in values:

Fill-in (1)

Amount of SSI under payment

Fill-in (2)

Choice 1: Beneficiary's Name possessive

Choice 2: your

OPT149 CROSS PROGRAM RECOVERY - T16 UNDERPAYMENT NOT USED TO REDUCED/RECOVER A T2 OVERPAYMENT (B89)

(System Generated)

Caption: What We Will Pay

We did not use any of 1 SSI benefits to recover an overpayment on this record.

Fill-in values:

Fill-in (1)

Choice 1: Beneficiary's Name

Choice 2: your

OPT151 OVERPAYMENT LIABILITY INFORMATION TO A REPRESENTATIVE PAYEE FOR OVERPAID BENEFICIARY (A27)

(Requested)

Caption: Your Benefits

As representative payee, you are personally liable for repayment unless you used the overpaid funds for the benefit of  (1)  , and the overpayment was made through no fault of your own.

Fill-in values:

Fill-in (1) – Systems Generated

Name(s) of beneficiary (ies)

OPT152 REPAY BENEFITS WITHHELD - PROTEST OF OVERPAYMENT RECEIVED TIMELY (LAF D to C ) (A44)

(Requested)

Caption: Your Benefits

We are paying  (1)  again beginning  (2)  because  (3)  asked us to review our overpayment decision. If we later find that our decision was correct, or that we cannot waive the overpayment,  (4)  will have to pay back the  (5)  which  (6)  . Someone from the local Social Security office will contact  (7)  to discuss the overpayment.

Fill-in values:

Fill-in (1) – Systems Generated

Choice 1: you

Choice 2: Beneficiary's Name

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

Date payments resumed MM/CCYY

Fill-in (3) – Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (4) – Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

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

Amount of overpayment

Fill-in (6) – Systems Generated

Choice 1: you owe

Choice 2: he owes

Choice 3: she owes

Fill-in (7) – Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

OPT153 OVERPAYMENT WITHHELD FROM BENEFITS IS REPAID — PROTEST RECEIVED TIMELY (A46)

(Requested)

Caption: Your Benefits

 (1)  asked us to review our overpayment decision. While we review  (2)  case, we are sending  (3)  the money we withheld from  (4)  checks.

If we later find that our decision was correct, or that we cannot waive the overpayment,  (5)  will have to pay back the  (6)  which  (7)  . Someone from the local Social Security office will contact  (8)  to discuss the overpayment.

Fill-in values:

Fill-in (1) – Systems Generated

Choice 1: You

Choice 2: Beneficiary's Name

Fill-in (2) – Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (3) – Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (4) – Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (5) – Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (6) Requested As A Money Amount In Format $$$$$.¢¢

Amount of overpayment-

Fill-in (7) – Systems Generated

Choice 1: you owe

Choice 2: he owes

Choice 3: she owes

Fill-in (8) – Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

OPT154 OVERPAYMENT PROTESTED - BENEFITS RESUMED AND WITHHELD BENEFITS REPAID - FOREIGN CLAIMS (A47)

(Requested)

Caption: Your Benefits

We are paying  (1)  again beginning  (2)  because  (3)  asked us to review our overpayment decision. If we later find that our decision was correct, or that we cannot waive the overpayment,  (4)  will have to pay back the  (5)  which  (6)  .

Fill-in values:

Fill-in (1) – Systems Generated

Choice 1: you

Choice 2: Beneficiary's name

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

Date payments resumed MM/CCYY

Fill-in (3) – Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (4) – Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

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

Amount of overpayment

Fill-in (6) – Systems Generated

Choice 1: you owe

Choice 2: he owes

Choice 3: she owes

OPT155 OVERPAYMENT PROTESTED - BENEFITS RESUMED - MONEY WITHHELD NOT REPAID - FOREIGN CLAIMS (A48)

(Requested)

Caption: Your Benefits

We are paying  (1)  again beginning  (2)  because  (3)  asked us to review our overpayment decision. For now, we are still withholding the money which we already subtracted from  (4)  checks.

If we later find that our decision was correct, or that we cannot waive the overpayment,  (5)  will have to pay back the  (6)  which  (7)  .

Fill-in values:

Fill-in (1) Systems Generated

Choice 1: you

Choice 2: Beneficiary's Name

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

Date payments resumed MM/CCYY

Fill-in (3) Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (4) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (5) Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (6) Requested As A Money Amount In Format $$$$$.¢¢

Amount of the remaining overpayment

Fill-in (7) Systems Generated

Choice 1: you owe

Choice 2: he owes

Choice 3: she owes

OPT156 OVERPAYMENT PROTESTED AFTER RECOVERY COMPLETED/STOPPED - REPAY BENEFITS WITHHELD - FOREIGN CLAIMS (A49)

(Requested)

Caption: Your Benefits

 (1)  asked us to review our overpayment decision. While we review  (2)  case, we are sending  (3)  the money we withheld from  (4)  checks. If we later find that our decision was correct, or that we cannot waive the overpayment,  (5)  will have to pay back the  (6)  which  (7)  .

Fill-in values:

Fill-in (1) Systems Generated

Choice 1: You

Choice 2: Beneficiary's Name

Fill-in (2) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (3) Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (4) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (5) Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (6) Requested As A Money Amount In Format $$$$$.¢¢

Amount of the overpayment

Fill-in (7) Systems Generated

Choice 1: you owe

Choice 2: he owes

Choice 3: she owes

OPT158 INTRODUCTORY STATEMENT FOR CAT A-A22 NOTICE WHEN OVERPAYMENT ESTABLISHED AND ALIEN TAXATION INVOLVED (ADMINISTRATIVE ADJUSTMENT) (F70)

(Requested)

Caption: None

We are writing to give  (1)  new information about the  (2)  benefits which  (3)  on this Social Security record. In the rest of this letter, we will tell  (4)  :

  • How we paid  (5)   (6)  too much in benefits; and

  • What to do if  (7)  we are wrong about the overpayment.

Fill-in values:

Fill-in (1) Systems Generated

Choice 1: you

Choice 2: Beneficiary's Name

Fill-in (2) Requested As A One Position Alpha Character

Choice 1: (A) disability

Choice 2: (B) retirement

Choice 3: (C) survivor

Choice 4: (D) auxiliary

Fill-in (3) Systems Generated

Choice 1: you receive

Choice 2: he receives

Choice 3: she receives

Fill-in (4) Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (5) Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (6) Requested As A Money Amount In Format $$$$$.¢¢

Amount of the overpayment

Fill-in (7) Systems Generated

Choice 1: you think

Choice 2: he thinks

Choice 3: she thinks

OPT159 A21 NOTICE OVERPAYMENT RECOVERY (G51)

(System Generated)

Caption: Your Benefits

As we told  (1)  in our previous letter, we are withholding  (2)  benefits to recover the overpayment of  (3)  .

Fill-in values:

Fill-in (1)

Choice 1: you

Choice 2: Beneficiary's Name

Fill-in (2)

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (3)

Amount of the overpayment

OPT161 INTRODUCTORY PARAGRAPH E31 AND E32 NOTICES (G70)

(System Generated)

Caption: None

We are writing to give  (1)  new information about the  (2)  benefits which  (3)  on this Social Security record. In the rest of this letter, we will tell  (4)  :

  • How we paid  (5)   (6)  too much in benefits; and

  • What to do if  (7)  we are wrong about the overpayment.

Fill-in values:

Fill-in (1)

Choice 1: you

Choice 2: Beneficiary's Name

Fill-in (2)

Choice 1: disability

Choice 2: retirement

Choice 3: survivor

Fill-in (3)

Choice 1: you receive

Choice 2: he receives

Choice 3: she receives

Fill-in (4)

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (5)

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (6)

Amount of the overpayment

Fill-in (7)

Choice 1: you think

Choice 2: he thinks

Choice 3: she thinks

OPT162 E31 AND E34 NOTICES MBP GREATER THAN OVERPAYMENT (G71)

(System Generated)

Caption: Your Benefits

We plan to collect the overpayment from the check which  (1)  will receive around  (2)  . We will reduce  (3)  check to  (4)  . We will send  (5)   (6)  regular monthly benefit amount again beginning  (7)  .

Fill-in values:

Fill-in (1)

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (2)

MM/DD/CCYY

Fill-in (3)

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (4)

Amount of the check

Fill-in (5)

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (6)

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (7)

MM/CCYY

OPT163 E34 NOTICE INTRODUCTORY PARAGRAPH (G72)

(System Generated)

Caption: None

We are writing to give  (1)  new information about Social Security benefits on this record. We paid  (2)   (3)  too much in Social Security benefits. In the rest of this letter, we will tell you:

  • How we paid too much in benefits, and

  • What to do if you think we are wrong about the overpayment.

Fill-in values:

Fill-in (1)

Choice 1: you

Choice 2: Beneficiary's name

Fill-in (2)

Beneficiary's name

Fill-in (3)

Amount of the Overpayment

OPT164 OVERPAYMENT RECOVERY PROPOSED AGAINST OTHER BENEFICIARY E34 NOTICE (G73)

(System Generated)

Caption: None

We cannot recover the overpayment from the person who was overpaid. For this reason, we will withhold the money from the checks of other persons who are paid on the same Social Security record.

Fill-in values:

None

OPT165 CHECK PARAGRAPH FUTURE WITHHOLDING OF OVERPAYMENT (G91)

(System Generated)

Caption: Your Benefits

We will pay  (1)  a monthly check of  (2)  until we start to collect the overpayment.

Fill-in values:

Fill-in (1)

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (2)

PMA or CMA in $$$$$.¢¢ format

OPT166 PREVIOUS CHECK WAS INCORRECT AMOUNT (M02)

(Requested)

Caption: Your Benefits

The check  (1)  received for  (2)  in  (3)  should have been for  (4)  . Therefore we paid  (5)   (6)  more in benefits than  (7)  due.

Fill-in values:

Fill-in (1) Systems Generated

Choice 1: you

Choice 2: Beneficiary's Name

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

Amount of check

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

MM/CCYY

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

Amount that should have been paid

Fill-in (5) Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (6) Requested As A Money Amount In Format $$$$$.¢¢

Amount of overpayment

Fill-in (7) Systems Generated

Choice 1: you were

Choice 2: he was

Choice 3: she was

OPT167 OVERPAYMENT RECOVERED (M06)

(Requested)

Caption: Your Benefits

We have recovered all of the money  (1)  owed because of an overpayment.

Fill-in values:

Fill-in (1) Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

OPT168 OVERPAYMENT BALANCE (M08)

(Requested)

Caption: Your Benefits

The total amount of the overpayment is  (1)  .

Fill-in values:

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

Amount of the overpayment

OPT169 INCORRECT BENEFIT CAUSED INCORRECT PAYMENT, OVERPAYMENT OR UNDERPAYMENT (M10)

(Requested)

Caption: Your Benefits

Since we paid  (1)   (2)  for  (3)  , we paid  (4)   (5)   (6)  than  (7)  due.

Fill-in values:

Fill-in (1) Systems Generated

Choice 1: you

Choice 2: Beneficiary's Name

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

Amount paid

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

Choice 1: MM/CCYY

Choice 2: MM/CCYY through MM/CCYY

Fill-in (4) Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

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

Amount of the overpayment

Fill-in (6) - Requested As A One Position Alpha Character

Choice 1: (A) more

Choice 2: (B) less

Fill-in (7) Systems Generated

Choice 1: you were

Choice 2: he was

Choice 3: she was

OPT170 BENEFITS DEFERRED TO RECOVER AN INCORRECT PAYMENT/OVERPAYMENT (M11)

(Requested)

Caption: Your Benefits

We are withholding all of  (1)  benefits for  (2)  and  (3)  of  (4)  benefits for  (5)  to recover the  (6)  that was not due

Fill-in values:

Fill-in (1) Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

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

Choice 1: MM/CCYY

Choice 2: MM/CCYY through MM/CCYY

Fill-in (3) Requested As A Money Amount In Format $$$$$.¢¢

Amount of final adjustment

Fill-in (4) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (5) Requested As A Date In Format Shown Below

MM/CCYY of final adjustment

Fill-in (6) Requested As A Money Amount In Format $$$$$.¢¢

Amount of overpayment or incorrect payment

OPT171 OTHER BENEFICIARY OVERPAID DUE TO WORK (M12)

(Requested)

Caption: Your Benefits

We paid  (1)   (2)  too much in benefits because of work and earnings in  (3)  .

Fill-in values:

Fill-in (1) - Requested As A Language

Name of overpaid beneficiary

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

Amount of overpayment

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

CCYY

OPT179 PAID VS. PAYABLE (M01)

(Requested)

Caption: Your Benefits

We paid  (1)   (2)  for  (3)  . Since we should have paid  (4)   (5)  for  (6)  , we paid  (7)   (8)   (9)  than  (10)  due.

Fill-in values:

Fill-in (1) Systems Generated

Choice 1: you

Choice 2: Beneficiary's Name

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

Amount

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

Choice 1: MM/CCYY

Choice 2: MM/CCYY through MM/CCYY

Fill-in (4) Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

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

Correct Amount

Fill-in (6) Requested As A Date in Format Shown Below

Choice 1: MM/CCYY

Choice 2: MM/CCYY through MM/CCYY

Fill-in (7) Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

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

Amount

Fill-in (9) Systems Generated

Choice 1: more

Choice 2: less

Fill-in (10) Systems Generated

Choice 1: you were

Choice 2: he was

Choice 3: she was

OPT180 FOREIGN REFUND REQUEST ADJUSTMENT PROPOSED OVERPAYMENT EXCEEDS MBP (F24)

(System Generated)

Caption: How To Pay Us Back

You should refund this overpayment within 30 days. Please make your check or money order payable to “Social Security Administration” and send it to us in the enclosed envelope.

Always include  (1)  Social Security claim number on the check or money order.

Please send your check or money order in United States currency or in local currency equal to the United States dollars. When you pay us in local currency, we use the exchange rate in effect at the time we get your payment. If this causes a difference between the amount you pay us and the amount you owe us, we will let you know. If you cannot mail your payment directly to us, please contact your Federal Benefits Unit for help in making the refund. Visit  (2)  for a list of Federal Benefits Units.

If we do not receive your refund within 30 days, we plan to recover the overpayment by withholding  (3)  full benefit each month beginning with the benefit  (4)  would normally receive about  (5)  . We will continue to withhold  (6)  benefit until the overpayment is fully recovered.

Fill-in values:

Fill-in (1) Systems Generated

Choice 1: your

Choice 2: Beneficiary Name possessive

Fill-in (2) Systems Generated

Choice 1: www.socialsecurity.gov/foreign/foreign.htm

Fill-in (3) Systems Generated

Choice 1: your

Choice 2: Beneficiary Name possessive

Fill-in (4) Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (5) Systems Generated

MM/DD/CCYY

Fill-in (6) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

OPT181 (M07) DUPLICATE CHECK OVERPAYMENT

(Requested)

Caption: Your Benefits

We sent  (1)  two checks for  (2) , both in the amount of  (3)  and both checks were cashed. Since  (4)  due only one check, we paid  (5)   (6)  too much in benefits.

Fill-in values:

Fill-in (1) Systems Generated

Choice 1: you

Choice 2: Beneficiary's name

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

MM/CCYY

Fill-in (3) Requested As A Money Amount In Format $$$$$.¢¢

Amount

Fill-in (4) Systems Generated

Choice 1: you were

Choice 2: he was

Choice 3: she was

Fill-in (5) Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (6) Requested As A Money Amount In Format $$$$$.¢¢

Amount of the overpayment

OPT182 PRIOR OVERPAYMENT — WORK MONTHS PREVENTED RECOVERY (A29)

(Requested)

Caption: Your Benefits

Our records show that we paid  (1)   (2)  too much in  (3)  . In our previous letter, we told  (4)  that we would withhold benefits in  (5)  to recover  (6)  amount. But  (7)  recent report shows that  (8)  worked during  (9)  . Because of that work, no benefits were payable for that period. Since we could not use benefits for those months to recover the amount  (10)  owed,  (11)  us  (12)  .

Fill-in values:

Fill-in (1) Systems Generated

Choice 1: Beneficiary's name

Choice 2: you

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

Amount of the overpayment

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

Year of prior overpayment in CCYY

Fill-in (4) Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (5) Requested As A Date in Format Shown Below

Choice 1: MM/CCYY

Choice 2: MM/CCYY through MM/CCYY

Fill-in (6) Requested As A One Position Alpha Character

Choice 1: (A) this

Choice 2: (B) part of this

Fill-in (7) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (8) Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (9) Requested As A Date in Format Shown Below

Choice 1: month and year of work MM/CCYY

Choice 2: months and years of work MM/CCYY through MM/CCYY

Fill-in (10) Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (11) Systems Generated

Choice 1: you still owe

Choice 2: he still owes

Choice 3: she still owes

Fill-in (12) Requested As A Money Amount In Format $$$$$.¢¢

Overpayment Amount

NL 00720.280 REF Referral

REF001 FIELD OFFICE REFERRAL DOMESTIC (G20)

(System Generated)

Caption: If You Have Any Questions

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) 

 (3) 

 (4) 

 (5) 

If you do call or visit an office, please have this letter with you. It will help us answer your questions.

Fill-in values:

No Fill-in needed

Office address line 1

Office address line 1

Office address line 2

Office address line 3

REF002 REFERRAL FOREIGN (G22)

(System Generated)

Caption: If You Have Any Questions

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, U.S.A. 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.

Fill-in values: :

Fill-in (1): www.socialsecurity.gov/foreign/foreign.htm

REF003 DOMESTIC REFERRAL PARAGRAPH (G28)

(System Generated)

Caption: If You Have Any Questions

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) 

 (3) 

 (4) 

 (5) 

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-in values:

FO Phone Number

Fill-ins

Choice 1: FO street address

Choice 2: city, state and zip code

FO Address

FO Address

FO Address

REF008 REFERRAL DOMESTIC DEFAULT (G21)

(System Generated)

Caption: If You Have Any Questions

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 value:

no Fill-in needed

REF127 RRB DOMESTIC REFERRAL PARAGRAPH NO LOCAL OFFICE TELEPHONE NUMBER (G32)

(System Generated)

Caption: If You Have Any Questions

We invite you to visit our website at  (1)  on the Internet to find general information about Social Security. However, if you have any specific  (2)  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:

 (3) 

If you do call or visit an office, please have this letter with you. It will help us answer your questions.

If you have any questions about railroad annuities or about your monthly check, please contact your local Railroad District Office by calling 1-877-772-5772 or you may write to the RRB. The address is U.S. Railroad Retirement Board, 844 Rush Street, Chicago, IL. 60611-2092.

Fill-in values:

Fill-in

www.socialsecurity.gov

Fill-in

Null

Fill-in

Street Address, City, State and Zip Code from DOORS

REF137 (GA7) BOND UTI

(System Generated)

Caption: If You Have Questions About The BOND Project

Please visit our website at  (1)  for general information about the Benefit Offset National Demonstration (BOND) project. If you have any questions about the BOND project, you may call our partner Abt Associates. Their toll-free number is 1-877-726-6309 (877-7BOND09). They will help you by phone or they will set up an appointment with the Abt local office that serves your area. If you have a hearing or speech impairment, you may call their TTY number, 1-877-726-6390 (877-7BOND90). When you call, please have this letter with you. It will help the counselors at Abt answer your questions.

Fill-in value:

Fill-in

www.BONDSSA.org

REF140 RRB FOREIGN REFERRAL PARAGRAPH (G38)

(System Generated)

Caption: If You Have Any Questions

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 should contact your Federal Benefits Unit. For a list of Federal Benefits Units, visit  (1) . You may also write the Social Security Administration, P.O. Box 17769, Baltimore, Maryland 21235-7769, U.S.A. Please be sure to include  (2)  Social Security claim number if you do write. However, if you visit an office, please take this letter. It will help the people there answer your questions. Medicare information is available on the Internet at www.medicare.gov.

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, IL. 60611-2092, U.S.A.

Fill-in values:

Fill-in (1) Systems Generated

Choice 1: www.socialsecurity.gov/foreign/foreign.htm

Fill-in (2) Systems Generated

Choice 1: your

Choice 2: Beneficiary's name possessive

REF141 REFERRAL DEFAULT (G39)

(System Generated)

Caption: If You Have Questions

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, 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.

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 value: None

REF142 RRB DOMESTIC REFERRAL PARAGRAPH (G29)

(System Generated)

Caption: If You Have Questions

We invite you to visit our website atwww.socialsecurity.gov  (1)  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  (2)  . 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:

 (3) 

 (4) 

 (5) 

 (6) 

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, IL. 60611-2092.

Fill-in values:

www.socialsecurity.gov

Office phone number in format 1-999-999-9999

Office address line 1

Office address line 2

Office address line 3

Office address line 4

NL 00720.295 RFU Refund

RFU001 REQUEST FOR REFUND - OVERPAID PERSON IN NONPAY STATUS NO CROSS PROGRAM ADJUSTMENT POSSIBLE (A19) (G13)

(Requested/Generated)

Caption: How To Pay Us Back

You should refund this overpayment of  (1)  within 30 days. Please make your check or money order payable to “Social Security Administration,” and send it to us in the enclosed envelope. Always include  (2)  Social Security claim number on your check or money order.

If you cannot refund the full  (3)  now, please send:

  • A partial payment

  • An explanation of why you cannot pay the full amount now, and

  • A plan to repay the money

Fill-in values:

Fill-in (1) – Systems Generated (when it is not requested on the ENB) or Requested As A Money Amount in Format $$$$$.¢¢

Overpayment Amount

Fill-in (2) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (3) Systems Generated (when it is not requested on the ENB) Requested As A Money Amount in Format $$$$$.¢¢

Overpayment Amount

RFU003 REQUEST FOR REFUND AND ADJUSTMENT PROPOSED - OVERPAID PERSON IN NONPAY STATUS AND IS REPRESENTATIVE PAYEE FOR OTHER - OVERPAYMENT EXCEEDS MONTHLY PAYMENT (A26)

(Requested)

Caption: How To Pay Us Back

You should refund this overpayment of  (1)  within 30 days. Please make your check or money order payable to “Social Security Administration,” and send it to us in the enclosed envelope.

Always include  (2)  Social Security claim number on your check or money order.

If we do not receive your refund within 30 days, we will hold back  (3)  full benefit starting with the payment you would normally receive  (4)  about

 (5) . We will continue holding back  (6)  benefits until we recover the overpayment.

If you cannot refund the full overpayment now or cannot afford to have us hold back  (7)  full benefit, you may ask us to hold back a smaller amount each month. Contact us to discuss your plan for repaying the balance. You may need to show us proof of  (8)  assets, monthly income, and expenses.

Fill-in values:

Fill-in (1) Systems Generated

Amount of Overpayment

Fill-in (2) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (3) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (4) Systems Generated

Choice 1: NULL

Choice 2: for him

Choice 3: for her

Fill-in (5) Systems Generated

MM/DD/CCYY

Fill-in (6) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (7) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (8) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

RFU007 SSI OFFSET NOT APPLICABLE (A59)

(Requested)

Caption: Your Benefits

Our records show that  (1)  did not get SSI money for  (2)  . So we can refund all of the Social Security money we held.

Fill-in values:

Fill-in (1) Systems Generated

Choice 1: you

Choice 2: Beneficiary's Name

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

Choice 1: MM/CCYY

Choice 2: MM/CCYY through MM/CCYY

RFU008 REFUND/RETURNED CHECK(S) USED TO REDUCE OVERPAYMENT (A34)

(Requested)

Caption: Your Benefits

We used the amount refunded to replace  (1)  the money we  (2)   (3)  .

Fill-in values:

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

Choice 1: (A) some of

Choice 2: (B) null

Fill-in (2) Requested As A One Position Alpha Character

Choice 1: (A) incorrectly paid

Choice 2: (B) overpaid

Fill-in (3) Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Choice 4: Beneficiary's Name

RFU012 REQUEST FOR REFUND AND ADJUSTMENT PROPOSED — OVERPAID PERSON IN CURRENT PAY — OVERPAYMENT EXCEEDS MONTHLY PAYMENT (A24)

(Requested/Generated)

Caption: How To Pay Us Back

You should refund this overpayment of $  (1)  within 30 days. Please make your check or money order payable to “Social Security Administration,” and send it to us in the enclosed envelope.

Always include  (2)  Social Security claim number on your check or money order.

If we do not receive your refund within 30 days, we will hold back  (3)  full benefit starting with the payment you would normally receive  (4)  about

 (5) . We will continue holding back  (6)  benefits until we recover the overpayment.

If you cannot refund the full overpayment now or cannot afford to have us hold back  (7)  full benefit, you may ask us to hold back a smaller amount each month. Contact us to discuss your plan for repaying the balance. You may need to show us proof of  (8)  assets, monthly income, and expenses.

Fill-in values:

Fill-in (1) - Systems Generated (when it is not requested on the ENB) Requested As A Money Amount in Format $$$$$.¢¢

Overpayment Amount

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (4) - Systems Generated

Choice 1: null

Choice 2: for him

Choice 3: for her

Fill-in (5) - Systems Generated (when it is not requested on the ENB) Requested As A Date In Format Shown Below

MM/DD/CCYY

Fill-in (6) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (7) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (8) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

RFU020 FOREIGN REFUND REQUEST NONPAY STATUS (F19)

Caption: How To Pay Us Back

(System Generated)

You should refund this overpayment within 30 days. Please make your check or money order payable to “Social Security Administration,” and send it to us in the enclosed envelope. Always include  (1)  Social Security claim number on the check or money order. If you cannot refund the full  (2)  now, you should submit:

  1. partial payment,

  2. an explanation of your financial circumstances, and

  3. a definite plan for repaying the balance.

If you pay us by check or money order, make sure that the check or money order is in United States (U.S.) dollars or in local currency equal to U.S. dollars. When you pay us in local currency, we use the exchange rates in effect at the time we get your payment. If this causes a difference between the amount you pay us and the amount you owe us, we will let you know. If you cannot mail your payment to us, please contact your Federal Benefits Unit. Visit  (3)  for a list of Federal Benefits Units. They will help you make the refund.

Fill-in values:

Fill-in (1) Systems Generated

Choice 1: Beneficiary's name possessive

Choice 2: your

Fill-in (2) Systems Generated

Overpayment amount in $$$$$¢¢

Fill-in (3) Systems Generated

www.socialsecurity.gov/foreign/foreign.htm



NL 00720 TN 09 - Manual Adjustment, Credit and Award Process (MADCAP) Beneficiary Notice Print Program - 06/29/2018