Identification Number:
NL 00730 TN 36
Intended Audience:See Transmittal Sheet
Originating Office:Systems
Title:Title II Redesign (T2R) Notices Title II Postentitlement (PE) Actions
Type:POMS Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part NL – Notices, Letters and Paragraphs
Chapter 007 – Letters and Paragraphs for Title II, Title XVI, and Title XVIII
Subchapter 30 – Title II Redesign (T2R) Notices Title II Postentitlement (PE) Actions
Transmittal No. 36, 09/23/2021

Audience

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

Originating Component

OSE

Effective Date

Upon Receipt

Background

We are updating Program Operations Manual System (POMS) sections in NL 00730 to incorporate the updates for the Universal Text Identifiers (UTIs) in the attached sections as a direct result of corrections requested by the Office of Program Law (OPL) and the Office of the General Council. These updates are effective immediately.

 

Summary of Changes

NL 00730.102 "A" Paragraphs and Captions

We updated the monetary amounts in the Fill-ins for the UTIs AET039 and AET042 to reflect decimal points that were missing.

We updated the Fill-in Values for the UTI AET041 by removing the erroneous text beside the Fill-in 6 indicator as that area should remain blank.

We also removed Fill-ins 2 and 3 from the Fill-in Values for the UTI ALS017 because they were not removed when the language for this UTI reverted back to having just one Fill-in.

Additionally, we corrected the text in Fill-in 4 of the UTI ATY067 by removing the erroneous text “plus has” in Choice 1.

 

NL 00730.110 “E” Paragraphs and Captions

We corrected the capitalization of Fill-in 1 Choice 2 of the UTIs ENT039 and ERNC05 to reflect a capital “Y” on the word “you” instead of a lowercase “y”. We also added the abbreviation for Number Holder (NH) to Choice 3 of Fill-in 1 in the UTI ERNC05.

 

NL 00730.130 "O" Paragraphs and Captions

We corrected the display of the monetary amount in Fill-in 3 of the UTI OPT131 from numeric to symbolic.

We also corrected the typo in the word “public” for the text in the UTI OPT246.

 

NL 00730.136 “R” Paragraphs and Captions

We corrected the text in the UTI RCY002 by removing the word “of” after Fill-in 8.

We corrected the publication number for Choice 3 in Fill-in 5 of the UTI REF020.

We updated the Fill-in text for Fill-in 3 of the UTI RIN006 to spell out the text for the abbreviation BGN.

We also updated the monetary amount in Fill-in 2 of the UTI RIN053 to reflect a decimal point that was missing.

 

NL 00730.102 "A" Paragraphs and Captions

List of “A” Paragraphs and Captions

A. ACT Universal Text Identifier – Privacy Act

ACT003 – PAPERWORK/PRIVACY ACT NOTICE PRINTED WHEN PAYMENT STUB IS PRINTED

Privacy Act Statement

The Social Security Administration (SSA) has authority to collect the information requested on the PAYMENT STUB under section 204 of the Social Security Act. Giving us this information is voluntary. You do not have to do it. We will need this information only if you choose to make payment by credit card. You do not need to fill out the credit card information if you choose another means of payment (for example, by check or money order).

If you choose the credit card payment option, we will provide the information you give us to the banks handling your credit card account and SSA's account. This will allow you to repay your overpayment with your credit card. We may also provide this information to another person or government agency to comply with federal laws requiring the release of information from our records. You can find these and other routine uses of information provided to SSA listed in the Federal Register. If you want more information about this, you may call or write any Social Security office.

We may also use the information you give us when we match records by computer. Matching programs compare our records with those of other Federal, State, or local government agencies. Many agencies may use matching programs to find or prove that a person qualifies for benefits paid by the Federal government. The law allows us to do this even if you do not agree to it.

Explanations about these and other reasons why information you provide us may be used or given out are available in Social Security offices. If you want to learn more about this, contact any Social Security office.

B. ADJ Universal Text Identifiers – Adjustment

ADJ048 – UNDERPAYMENT TRANSFERRED FROM DECEASED BENEFICIARY TO SPOUSE

(1) will soon receive a payment of (2) because we owed money to (3). This payment is in addition to any monthly payments (4) may receive.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

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

Fill-in (2)

Amount of underpayment transferred from deceased beneficiary to spouse

Fill-in (3)

 

Choice 1

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) of deceased beneficiary (if Beneficiary Identification Code (BIC) is A)

Choice 2

your spouse

Choice 3

his spouse

Choice 4

her spouse

Choice 5

NOT USED BY T2R

Name of deceased beneficiary (non-possessive)

Fill-in (4)

 

Choice 1

you

Choice 2

he

Choice 3

she

C. AET Universal Text Identifier – Annual Earnings Test

AETC02 – CAPTION

You May Be Due More Benefits

AETC06 – CAPTION

What We Will Do

AETC07 – CAPTION

The Yearly Earnings Limit

AETC08 – CAPTION

A Special Rule That Applies To Earnings In One Year

AETC09 – CAPTION

If Your Expected Earnings Change

AETC10 – CAPTION

If You Work For Wages

AETC11 – CAPTION

If You Are Self-Employed

AETC12 – CAPTION

If You Work For Wages and Are Self-Employed

AETC14 – CAPTION

How We Calculate Earnings

If You Work For Wages and Are Self-Employed

AETH01 – HEADER

How Work Affects Your Social Security

AETH02 – HEADER

How To Estimate Earnings

AET036 – INFORMATIONAL PARAGRAPH TO THE BENEFICIARY ABOUT HOW EARNINGS HAVE AFFECTED HIS OR HER SOCIAL SECURITY BENEFITS

Please read the rest of this letter carefully. In it, we explain the changes we are making to (1) benefits. We also tell you how (2) earnings have affected (3) benefits and what to do if you disagree with any of our decisions.

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

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

Fill-in (2)

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

AET037 – REFER TO WORKSHEET HEADER NL 00730.149D

AET038 – PROVIDES THE LAST MONTHLY EARNINGS TEST YEAR’S INCOME LIMITS AND THE BENEFICIARY'S NON-SERVICE MONTHS FOR THE LAST MONTHLY EARNINGS TEST YEAR

In addition, you told us that (1) did not (2) more than (3) a month and did not work over 45 hours a month in self-employment (4) (5).

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

you

Fill-in (2)

 

Choice 1

expect to earn

Choice 2

earn

Fill-in (3)

 

Choice 1

Full Retirement Age (FRA) year exempt amount divided by 12 in the format $$$$$.¢¢

EXAMPLE:

If the FRA year = 2012, then the exempt amount = $38, 880. Divide the exempt amount by 12.

$38,880 12 = 3240

(show this amount in Fill-in (3))

Choice 2

Pre-Full Retirement Age (FRA) year exempt amount divided by 12 in the format $$$$$.¢¢

EXAMPLE:

If the PRE-FRA year = 2012 and the exempt amount = $14,640,

Divide $14,640 12 =1220 (show this amount in Choice 2)

Fill-in (4)

 

Choice 1

from

Choice 2

in

Choice 3

through

Fill-in (5)

 

Choice 1

First non-service month

Choice 2

and

Choice 3

comma (,)

AET039 – INTRODUCTORY PARAGRAPH FOR THE BENEFICIARY ABOUT THE ANNUAL EARNINGS LIMIT FOR SPECIFIC YEARS

The earnings limit for (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11). If (12) over the allowed amount for the year, we withhold $1 in benefits for every (13) (14) above the limit. We have enclosed a worksheet to show how we applied the earnings limit to (15) earnings to figure (16) benefits.

For more information about the earnings limit, see the enclosed fact sheet called, "How Work Affects Your Social Security."

Fill-in values:

 

Fill-in (1)

 

Choice 1

CCYY plus ”is”

Fill-in (2)

 

Choice 1

Annual Earnings Test (AET) amount for this Year of Earnings Report (YOER) in the format $$$$$$.¢¢

Fill-in (3)

 

Choice 1

and for

Choice 2

comma (,)

Choice 3

Null

Fill-in (4)

 

Choice 1

CCYY plus ”is”

Choice 2

Null

Fill-in (5)

 

Choice 1

Annual Earnings Test (AET) amount for this Year of Earnings Report (YOER) in the format $$$$$$.¢¢

Choice 2

Null

Fill-in (6)

 

Choice 1

and for

Choice 2

comma (,)

Choice 3

Null

Fill-in (7)

 

Choice 1

CCYY plus ”is”

Choice 2

Null

Fill-in (8)

 

Choice 1

Annual Earnings Test (AET) amount for this Year of Earnings Report (YOER) in the format $$$$$$.¢¢

Choice 2

Null

Fill-in (9)

 

Choice 1

and for

Choice 2

Null

Fill-in (10)

 

Choice 1

CCYY plus ”is”

Choice 2

Null

Fill-in (11)

 

Choice 1

Annual Earnings Test (AET) amount for this Year of Earnings Report (YOER) in the format $$$$$$.¢¢

Choice 2

Null

Fill-in (12)

 

Choice 1

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) plus “works and earns”

Choice 2

“you” plus “work and earn”

Fill-in (13)

 

Choice 1

$2

Choice 2

$3

Choice 3

$2 or $3

Fill-in (14)

 

Choice 1

he earns

Choice 2

she earns

Choice 3

you earn

Fill-in (15)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (16)

 

Choice 1

his

Choice 2

her

Choice 3

your

AET040 – PARAGRAPH TO A NON-RESPONDER (NRP) WITH A MID-YEAR MAILER INDICATOR ON THE MASTER BENEFICIARY RECORD (MBR) EXPLAINING THAT SINCE HE OR SHE DID NOT PROVIDE AN ESTIMATE OF EARNINGS FOR THE CURRENT YEAR, WE WILL USE LAST YEAR'S EARNINGS AS THE CURRENT YEAR ESTIMATE

Earlier we asked you to estimate (1) earnings for (2). We need this estimate to decide how much Social Security benefits to pay (3) for (4). We have not heard from you. Unless you contact us with a new estimate, we will use the same estimate we used in (5) to decide (6) benefits for (7).

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

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

Fill-in (2)

Current Operating Year (COY) in the format CCYY

Fill-in (3)

 

Choice 1

you

Choice 2

him

Choice 3

her

Fill-in (4)

Current Operating Year (COY) in the format CCYY

Fill-in (5)

Current Operating Year (COY) – 1 (the last year for which we have an estimate) in the format CCYY

Fill-in (6)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (7)

Current Operating Year (COY) in the format CCYY

AET041 – PARAGRAPH TO A NON-RESPONDER (NRP) WITH NO MID-YEAR MAILER INDICATOR ON THE MASTER BENEFICIARY RECORD (MBR) EXPLAINING THAT SINCE HE OR SHE DID NOT PROVIDE AN ESTIMATE OF EARNINGS FOR THE CURRENT YEAR. WE WILL USE LAST YEAR’S EARNINGS AS THE CURRENT YEAR ESTIMATE.

We base the amount of Social Security benefits (1) due on (2) estimated earnings. In (3), (4) earnings estimate was (5). Unless you contact us with a new estimate, we will use that same estimate to decide (6) benefits for (7).

Fill-in values:

 

Fill-in (1)

 

Choice 1

you are

Choice 2

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

Fill-in (2)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (3)

Current Operating Year (COY) – 1 (the last year for which we have an estimate in the format CCYY

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (5)

Post-MBR Amount of Reported Earnings (AORE) from the last estimate in the format $$$$$¢¢

Fill-in (6)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (7)

Current Year in the format CCYY

AET042 – PARAGRAPH TO A WORKING BENEFICIARY THAT SINCE HE OR SHE DID NOT PROVIDE AN ESTIMATE OF EARNINGS FOR THE CURRENT YEAR, WE WILL USE THE EARNINGS REPORTED BY HIS OR HER EMPLOYER LAST YEAR AS THE CURRENT YEAR ESTIMATE.

In (1), we based the amount of (2) Social Security benefits on earnings of (3) that (4) employer reported. We will use the same amount of earnings to decide (5) benefits in (6). That is, unless you contact us with a new estimate of (7) expected earnings for (8).

Fill-in values:

 

Fill-in (1)

Current Operating Year (COY) – 1 in the format CCYY

Fill-in (2)

 

Choice 1

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

Choice 2

your

Fill-in (3)

Post-MBR Amount of Reported Earnings (AORE) in the format $$$$$.¢¢

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (6)

Current Operating Year (COY) in the format CCYY

Fill-in (7)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (8)

Current Operating Year (COY) in the format CCYY

AET043 – REQUEST TO BENEFICIARY ASKING THEM TO NOTIFY SOCIAL SECURITY ADMINISTRATION IF HIS OR HER WORK ESTIMATE IS NOT CORRECT

(1) work plans may have changed and we want to make sure that we are paying (2) correctly. So, please check (3), and let us know right away if you think (4) will earn more or less than (5) in (6).

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

Your

Fill-in (2)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (3)

 

Choice 1

his estimate

Choice 2

her estimate

Choice 3

your estimate

Choice 4

his expected earnings

Choice 5

her expected earnings

Choice 6

your expected earnings

Fill-in (4)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (5)

Amount of Reported Earnings (AORE) in the format $$$$$.¢¢

Fill-in (6)

The Year of Earnings Report (YOER) in the format CCYY

AET044 – EXPLAINS TO A DIVORCED AUXILIARY SPOUSE THAT A FORMER SPOUSE'S WORK NO LONGER AFFECTS BENEFITS

(1) told us (2) divorce was final in (3). Once (4) been divorced for 2 years, (5) former spouse’s work no longer affects (6) benefits. Therefore, beginning (7), we will no longer withhold or reduce (8) benefits because of (9) former spouse's work.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

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

Fill-in (2)

 

Choice 1

your

Choice 2

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

Choice 3

his

Choice 4

her

Fill-in (3)

Marriage End Date (MARR-END-REL-D)

Fill-in (4)

 

Choice 1

you have

Choice 2

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

Choice 3

he has

Choice 4

she has

Fill-in (5)

 

Choice 1

your

Choice 2

his

Choice 3

her

Choice 4

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

Fill-in (6)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (7)

Effective date of change in the format Month CCYY

Fill-in (8)

 

Choice 1

your

Choice 2

his

Choice 3

her

Choice 4

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

Fill-in (9)

 

Choice 1

your

Choice 2

his

Choice 3

her

AET045 – REFER TO WORKSHEET HEADER NL 00730.149A

AET046 – REFER TO WORKSHEET HEADER NL 00730.149A

AET047 – REFER TO WORKSHEET HEADER NL 00730.149A

AET048 – REFER TO WORKSHEET HEADER NL 00730.149B

AET049 – REFER TO WORKSHEET HEADER NL 00730.149B

AET050 – REFER TO WORKSHEET HEADER NL 00730.149B

AET051 – REFER TO WORKSHEET HEADER NL 00730.149D

AET052 – REFER TO WORKSHEET HEADER NL 00730.149D

D. AGE Universal Text Identifier – Age

AGE002 – EXPLANATION OF FULL RETIREMENT AGE (FRA) ATTAINMENT WHEN BORN ON THE FIRST DAY OF THE MONTH

Because (1) born on the first day of the month, we consider (2) (3) the month before.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

you were

Fill-in (2)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (3)

 

Choice 1

Null

Choice 2

to have reached full retirement age

E. ALS Universal Text Identifiers – Appeals

ALSC04 – CAPTION

If You Disagree With The Decision

ALSC06 – CAPTION

Do You Think We Are Wrong About The Overpayment

ALS017 – APPEALS LANGUAGE FOR MONTHLY BENEFIT PAYABLE (MBP) CHANGE DUE TO A THIRD-PARTY ACTION

If you disagree with the change we have made to (1) monthly payment, you have the right to appeal. We will review your case and look at any new facts you have. A person who did not make the first decision will decide your case.

  • You have 60 days to ask for an appeal.

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

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

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

ALS020 – GENERAL APPEALS LANGUAGE

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

  • You have 60 days to ask for an appeal in writing.

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

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

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

Fill-in values:

 

Fill-in (1)

www.socialsecurity.gov/online/

ALS100 – PAYMENTS WILL CONTINUE WHILE THE APPEAL OF MEDICAL CESSATION IS PENDING

(1) entitled to have (2) payments continued until we notify (3) of the appeal decision made on (4) case. If (5)(6) appeal, (7) may have to pay some, or all, of this money back unless we are able to waive repayment.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You are

Choice 2

Disabled Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) plus "is"

Fill-in (2)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (3)

 

Choice 1 you
Choice 2 him
Choice 3 her

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (5)

 

Choice 1

you lose

Choice 2

he loses

Choice 3

she loses

Fill-in (6)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (7)

 

Choice 1

you

Choice 2

he

Choice 3

she

F. ANP Universal Text Identifier – Outside the U.S.

ANP003 – BENEFICIARY OUTSIDE U.S. (Pub-05-10137)

Please read the enclosed pamphlet, “Social Security: Your Payments While You Are Outside the United States.” It explains what (1) will need to do to start receiving payments again.

Fill-in values:

 

Fill-in (1)

 

Choice 1

“Mr.” plus Beneficiary’s Last Name (BLN)

Choice 2

“Ms.” plus Beneficiary’s Last Name (BLN)

Choice 3

you

G. AST Universal Text Identifier – Equitable relief

ASTC02 – CAPTION

Information About (1) Installment Payment

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

Your

H. ATY Universal Text Identifiers – Representative Fee

ATYC01 – CAPTION

Information About Representatives Fees

ATYC03 – CAPTION

Information About Past-Due Benefits Withheld To Pay A Representative

ATY067 – SUPPLEMENTAL SECURITY INCOME OFFSET HAS BEEN DETERMINED – PAST DUE BENEFITS BEING RELEASED TO BENEFICIARY AND REPRESENTATIVE HAS NOT REGISTERED FOR DIRECT PAYMENT

If a representative, who is a (1), registers with us to receive direct fee payment, because of the law we usually withhold part of the past-due benefits to pay the fee we approve. Although (2) representative is a (3), he or she did not register for direct payment before we completed our work on (4) claim. For that reason, we did not withhold from (5) past-due benefits to pay the fee we approve. Therefore, the Social Security Administration is not involved in paying the fee. This is a matter between (6) and (7) (8).

Fill-in values:

 

Fill-in (1)

 

Choice 1

lawyer

Choice 2

participant in the non-attorney direct payment demonstration project

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

lawyer

Choice 2

participant in the demonstration project

Fill-in (4)

 

Choice 1

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

Choice 2

your

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (6)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (7)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (8)

 

Choice 1

lawyer

Choice 2

representative

ATY836 – EXPLANATION TO THE BENEFICIARY ABOUT THE WITHHOLDING OF REPRESENTATIVE FEES FROM PAST-DUE BENEFITS

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

Fill-in values:

 

Fill-in (1)

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

Fill-in (2)

 

Choice 1

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

Choice 2

your

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

NL 00730.110 “E” Paragraphs and Captions

List of “E” Paragraphs and Captions

A. “ENC” Universal Text Identifier – Enclosures

ENC003 – ENCLOSURE REMARKS

If

Publication

HIB086 is generated

CMS Refund Envelope (English Only)

HIB225 is generated

CMS Refund Envelope (English Only)

LANG=S and Notice Completion Code=S, R, I or M

Spanish

REF020 is generated and domestic address and TAC-CD=D

Pub 05-10077 (English)

 

Pub 05-10977 (Spanish)

ENT026 is generated and domestic address and TAC-CD=D

Pub 05-10077 (English)

 

Pub 05-10977 (Spanish)

ENT047 is generated and domestic address and TAC-CD=D

Pub 05-10077 (English)

 

Pub 05-10977 (Spanish)

ENT026 is generated and domestic address and TAC-CD=D

Pub 05-10153 (English)

 

Pub 05-10903 (Spanish)

ENT027 is generated and domestic address and TAC-CD=D

Pub 05-10153 (English)

 

Pub 05-10903 (Spanish)

ENT026 is generated and domestic address and TAC-CD=D

Pub 05-10153 (English)

 

Pub 05-10903 (Spanish)

REF020 is generated and foreign address

Pub 05-10137 (English)

 

Pub 05-10138 (Spanish)

COA011 is generated and foreign address

Pub 05-10137 (English)

 

Pub 05-10138 (Spanish)

ENT026 is generated and foreign address

Pub 05-10137 (English)

 

Pub 05-10138 (Spanish)

ENT047 is generated and foreign address

Pub 05-10137 (English)

 

Pub 05-10138 (Spanish)

ANP003 is generated

Pub 05-10137 (English)

 

Pub 05-10138 (Spanish)

RPY041 is generated

Pub 05-10076 (English)

 

Pub 05-10976 (Spanish)

RFU001

SSA-3105 (English Only)

WAV001

SSA-3105 (English Only)

CFD004

Refund Envelope

RFU001

Refund Envelope

RFU012

Refund Envelope

OPT147

Refund Envelope

WCP003

Pub 05-10007 (English Only)

GPO001

Pub 05-10007 (English Only)

SUS047

Pub 05-10007 (English Only)

B. “ENT” Universal Text Identifiers – Entitlement

ENT004 – MATURING ACTION – LEDGER ACCOUNT FILE (LAF) C TO LAF S FOR LESSDO FOR SUPPLEMENTAL MEDICAL INSURANCE

We told (1) earlier that when we started paying (2) benefits, we would adjust them for medical insurance premiums.

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

you

Fill-in (2)

 

Choice 1

him

Choice 2

her

Choice 3

you

ENT007 – MATURING ACTION – SUPPLEMENTAL MEDICAL INSURANCE DEDUCTED FROM BENEFITS

(1) will get benefits starting (2). We told (3) earlier that when we started paying (4) benefits, we would adjust them for medical insurance premiums.

Fill-in values:

Fill-in (1)

 

Choice 1

You

Choice 2

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

Fill-in (2)

Current Operating Month (COM) in the format Month CCYY

Fill-in (3)

 

Choice 1

you

Choice 2

him

Choice 3

her

Fill-in (4)

 

Choice 1

you

Choice 2

him

Choice 3

her

ENT009 – LUMP SUM DEATH PAYMENT (LSDP) PAID TO WIDOW(ER) – NUMBER HOLDER (NH) DIED

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

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

You

Fill-in (2)

 

Choice 1

is

Choice 2

are

Fill-in (3)

Lump Sum Amount Paid (LSAP) in the format $$$$$.¢¢

Fill-in (4)

NH-NAME

Fill-in (5)

Null

ENT026 – FOR CERTAIN AWARDS, FULL RETIREMENT AGE (FRA), ENTITLEMENT CONVERSIONS

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

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

You

Fill-in (2)

 

Choice 1

is

Choice 2

are

Fill-in (3)

 

Choice 1

father's

Choice 2

mother's

Choice 3

child's

Choice 4

retirement

Choice 5

widower's

Choice 6

widow's

Fill-in (4)

Historical Date of Entitlement Start (BCLM-DOE-START-REL)

ENT036 – BENEFICIARY IDENTIFICATION CODE (BIC) B OR E TERMINATED DUE TO LAST CHILD IN CARE

(1) may be able to receive payments once more if (2) (3) taking care of a child of (4). The child must be under age 16 or disabled and qualify for child's payments. If (5) (6) to do this, (7) should get in touch with us again.

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

You

Fill-in (2)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (3)

 

Choice 1

again starts

Choice 2

again start

Fill-in (4)

Number Holder’s Name (NH-NAME)

Fill-in (5)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (6)

 

Choice 1

starts

Choice 2

start

Fill-in (7)

 

Choice 1

he

Choice 2

she

Choice 3

you

ENT039 – STUDENT TERMINATION PRIOR TO AGE 19

(1) may be able to receive payments again if (2) (3) an elementary or secondary level school full-time during any month before age 19. If this happens, (4) should get in touch with us again.

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

You

Fill-in (2)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (3)

 

Choice 1

attends

Choice 2

attend

Fill-in (4)

 

Choice 1

he

Choice 2

she

Choice 3

you

ENT041 – BENEFICIARY IDENTIFICATION CODE (BIC) B2 TO B BASED ON AGE

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

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

You are

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

Historical Date of Entitlement Start (BCLM-DOE-START-REL) date in format Month CCYY

Choice 2

Historical Date of Entitlement Start (BCLM-DOE-START-REL) date plus “and” plus the BCLM-DOE-START-REL plus 1 month in the format Month CCYY and Month CCYY

Choice 3

Historical Date of Entitlement Start (BCLM-DOE-START-REL) plus “through” plus the Historical Date of Entitlement Termination (BCLM-DOE-TERM-REL) date minus 1 month in the format Month CCYY through Month CCYY

Fill-in (4)

Historical Date of Entitlement Start (BCLM-DOE-START-REL) for the new Beneficiary Claim Data (BCLM) occurrence for PIC B

Fill-in (5)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (6)

 

Choice 1

his

Choice 2

her

Choice 3

your

ENT047 – STUDENT AWARD OR STUDENT CHILDHOOD DISABILITY BENEFIT (CDB) AWARD

(1) (2) for child's payments as a student beginning (3).

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

You

Fill-in (2)

 

Choice 1

qualifies

Choice 2

qualify

Fill-in (3)

Historical Date of Entitlement Start (BCLM-DOE-START-REL) in the Beneficiary Claim Data (BCLM) occurrence with the Historical Current Entitlement Code (BCLM-CEC) = Student (S)

ENT049 – STUDENT AWARD OR STUDENT REINSTATEMENT

Based on the information we have, (1) entitlement will continue through (2). We will send (3) another letter when (4) entitlement ends.

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

No Longer in Full-Time Attendance Date (SRD-NLFTA-REL) in the format Month CCYY

Choice 2

End of Full-Time Attendance Date (SRD-EFTA-REL) in the format Month CCYY

Choice 3

Student Entitlement High School Graduation Date (SRD-HSGRAD-REL) in the format Month CCYY

Choice 4

End of Full-Time Attendance Date (SRD-EFTA-REL) in the format Month CCYY

Fill-in (3)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

ENT053 – MONTHLY BENEFIT AMOUNT (MBA) EQUAL ZERO DUE TO DISABILITY MAXIMUM (DMAX) - (HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF TECHNICAL ENTITLEMENT (TECENT)

We cannot pay benefits because all of the money we can pay on this record is already being paid to (1).

Fill-in values:

Fill-in (1)

Number Holder Name (NH-NAME)

ENT060 – B TO D CONVERSION WHEN NUMBER HOLDER DIES

We have not determined the amount of (1) monthly (2) benefit payment. When we complete our review of (3) record, you will receive another notice explaining (4) entitlement to (5) benefits.

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

widower's

Choice 2

widow's

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

widower's

Choice 2

widow's

ENT061 – STUDENT TERMINATION PRIOR TO AGE 19

(1) also may be able to receive payments again if (2) (3) disabled before age 22 and (4) not married since (5) last entitlement, unless the marriage is void or annulled. If this happens, (6) should get in touch with us again.

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

You

Fill-in (2)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (3)

 

Choice 1

becomes

Choice 2

become

Fill-in (4)

 

Choice 1

has

Choice 2

have

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (6)

 

Choice 1

he

Choice 2

she

Choice 3

you

ENT062 – NO CHANGE IN THE MONTH OF ELECTION (MOEL) DATA BASED ON THE ANNUAL REPORT DATA

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)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

Pre-MBR Historical Date of Entitlement Start (BCLM-DOE-START-REL)

Fill-in (6)

Post-MBR Historical Date of Entitlement Start (BCLM-DOE-START-REL)

ENT070 – DISABILITY INSURANCE BENEFITS (DIB) TO RETIREMENT INSURANCE BENEFITS (RIB) AT FULL RETIREMENT AGE (FRA) WHEN PAYMENT IDENTIFICATION CODE (PIC) A CONFIRMS DATE OF BIRTH

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

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

you were

Fill-in (2)

Payment Identification Code (PIC) A's date of birth in the format Month DD, CCYY

ENT071 – DISABILITY INSURANCE BENEFITS (DIB) TO RETIREMENT INSURANCE BENEFITS (RIB) AT FULL RETIREMENT AGE (FRA) FOR PIC A

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

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

Choice 2

you receive

Fill-in (2)

Full Retirement Age (FRA) attainment month for Payment Identification Code (PIC) A in the format Month 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

C. “ERN” Universal Text Identifiers – Earnings

ERNC03 – CAPTION

Some Earnings May Not Count

ERNC04 – CAPTION

The Earnings Limit

ERNC05 – CAPTION

Based On (1) (2) Earnings

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

Your

Choice 3

Number Holder (NH) First Name plus NH Last name (possessive)

Choice 4

Null

Fill-in (2)

 

Choice 1

Expected

Choice 2

Null

ERNC06 – REFER TO WORKSHEET HEADER NL 00730.149D

ERNH01 – REFER TO WORKSHEET HEADER NL 00730.149D

ERN009 – PROVIDES THE AMOUNT A BENEFICIARY EXPECTS TO EARN IN THE CURRENT YEAR

Our records also show that (1) to earn (2) this year.

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

you expect

Fill-in (2)

Amount of Reported Earnings (AORE) in the format $$$$$.¢¢

ERN010 – EARNINGS THAT DO NOT AFFECT SOCIAL SECURITY BENEFITS.

We may not have to count all of the earnings reported for (1) in (2). Only the wages that (3) in a given year may affect Social Security benefits for that year. Here are some types of earnings that we don't count:

  • bonuses, vacation or sick pay, severance pay, or

  • commissions that (4) in one year, but do not earn in the same year;

  • retirement payments from a pension fund that may have been reported as wages.

Please contact us and let us know if (5):

  • received some money in (6) but actually earned the money before (7); or

  • earned a different amount in (8); or

  • had a net loss from self-employment in (9).

If (10) self-employed and had a net loss, we can subtract the amount of the loss from (11) wages for (12). If (13) self-employed, we won't count any income (14) received after (15) became entitled to Social Security if that income is for work performed before (16) became entitled to Social Security.

Fill-in values:

Fill-in (1)

 

Choice 1

you

Choice 2

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

Fill-in (2)

 

Choice 1

Year of Earnings Report (YOER) in the format CCYY

Choice 2

Years of Earnings Report (YOER) in the format CCYY plus “and” plus CCYY

Choice 3

Years of Earnings Report (YOER) in the format CCYY plus “through” plus CCYY

Fill-in (3)

 

Choice 1

you actually earn

Choice 2

he actually earns

Choice 3

she actually earns

Choice 4

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

Fill-in (4)

 

Choice 1

you receive

Choice 2

he receives

Choice 3

she receives

Choice 4

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

Fill-in (5)

 

Choice 1

you

Choice 2

he

Choice 3

she

Choice 4

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

Fill-in (6)

 

Choice 1

Year of Earnings Report (YOER) in the format CCYY

Choice 2

Years of Earnings Report (YOER) in the format CCYY plus “or” plus CCYY

Choice 3

Years of Earnings Report (YOER) in the format CCYY plus “or” plus CCYY plus “or” plus CCYY

Fill-in (7)

 

Choice 1

that year

Choice 2

these years

Fill-in (8)

 

Choice 1

Year of Earnings Report (YOER) in the format CCYY

Choice 2

Years of Earnings Report (YOER) in the format CCYY plus “or” plus CCYY

Choice 3

Years of Earnings Report (YOER) in the format CCYY plus “or” plus CCYY plus “or” plus CCYY

Fill-in (9)

 

Choice 1

Year of Earnings Report (YOER) in the format CCYY

Choice 2

Years of Earnings Report (YOER) in the format CCYY plus “or” plus CCYY

Choice 3

Years of Earnings Report (YOER) in the format CCYY plus “or” plus CCYY plus “or” plus CCYY

Fill-in (10)

 

Choice 1

you were

Choice 2

he was

Choice 3

she was

Choice 4

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

Fill-in (11)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (12)

 

Choice 1

that year

Choice 2

these years

Fill-in (13)

 

Choice 1

you are

Choice 2

he is

Choice 3

she is

Choice 4

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

Fill-in (14)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (15)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (16)

 

Choice 1

you

Choice 2

he

Choice 3

she

Choice 4

Beneficiary’s Given Name (BGN)

ERN016 – REFER TO WORKSHEET HEADER NL 00730.149D

ERN019 – REFER TO WORKSHEET HEADER NL 00730.149D

ERN021 – EARNINGS CHANGE BUT BENEFITS ARE NOT CHANGING

We are writing to you about (1) work and earnings for (2). Our records show that (3) (4) (5).

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

Year of Earnings Report (YOER) in the format CCYY

Choice 2

comma (,)

Choice 3

and

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

 

Choice 1

expects to earn

Choice 2

expect to earn

Choice 3

earned

Fill-in (5)

 

Choice 1

Amount of Reported Earnings (AORE) in the format $$$$$¢¢ plus “in” plus Year of Earnings Report (YOER)

Choice 2

comma (,)

Choice 3

and

ERN022 – FULL RETIREMENT AGE (FRA) YEAR ANNUAL EARNINGS TEST

In the year (1) age (2), we only count (3) earnings for months before (4) age (5). If (6) less than (7) in the months before (8) age (9), (10) can get all of (11) benefits. Our records show (12) became age (13) on (14). We figured (15) earned about (16) in the months before full retirement age.

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

you become

Fill-in (2)

Full Retirement Age (FRA) - using the choices below

Choice 1

65

Choice 2

65 and 2 months

Choice 3

65 and 4 months

Choice 4

65 and 6 months

Choice 5

65 and 8 months

Choice 6

65 and 10 months

Choice 7

66

Choice 8

66 and 2 months

Choice 9

66 and 4 months

Choice 10

66 and 6 months

Choice 11

66 and 8 months

Choice 12

66 and 10 months

Choice 13

67

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

 

Choice 1

he turns

Choice 2

she turns

Choice 3

you turn

Fill-in (5)

Full Retirement Age (FRA) - using the choices below

Choice 1

65

Choice 2

65 and 2 months

Choice 3

65 and 4 months

Choice 4

65 and 6 months

Choice 5

65 and 8 months

Choice 6

65 and 10 months

Choice 7

66

Choice 8

66 and 2 months

Choice 9

66 and 4 months

Choice 10

66 and 6 months

Choice 11

66 and 8 months

Choice 12

66 and 10 months

Choice 13

67

Fill-in (6)

 

Choice 1

he earns

Choice 2

she earns

Choice 3

you earn

Fill-in (7)

Annual exempt amount

Fill-in (8)

 

Choice 1

he turns

Choice 2

she turns

Choice 3

you turn

Fill-in (9)

Full Retirement Age (FRA) - using the choices below

Choice 1

65

Choice 2

65 and 2 months

Choice 3

65 and 4 months

Choice 4

65 and 6 months

Choice 5

65 and 8 months

Choice 6

65 and 10 months

Choice 7

66

Choice 8

66 and 2 months

Choice 9

66 and 4 months

Choice 10

66 and 6 months

Choice 11

66 and 8 months

Choice 12

66 and 10 months

Choice 13

67

Fill-in (10)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (11)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (12)

 

Choice 1

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

Choice 2

you

Fill-in (13)

Full Retirement Age (FRA) - using the choices below

Choice 1

65

Choice 2

65 and 2 months

Choice 3

65 and 4 months

Choice 4

65 and 6 months

Choice 5

65 and 8 months

Choice 6

65 and 10 months

Choice 7

66

Choice 8

66 and 2 months

Choice 9

66 and 4 months

Choice 10

66 and 6 months

Choice 11

66 and 8 months

Choice 12

66 and 10 months

Choice 13

67

Fill-in (14)

Full Retirement Age (FRA) attainment date

Fill-in (15)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (16)

Amount of Reported Earnings (AORE) in the format $$$$$$$.¢¢

ERN025 – CALCULATIONS OF THE BENEFICIARY’S PRE-FULL RETIREMENT AGE (FRA) EARNINGS IN THE FULL RETIREMENT AGE (FRA) YEAR

Here is how we figured (1) earnings for the months before (2) became age (3). First, we had to find (4) average earnings for each month. Our records show (5) earned (6) in (7). So we divided these earnings by 12 (the number of months in a year). Then, we multiplied this number times (8), which is the number of months before (9) turned age (10). Based on this, we figure (11) earned about (12) in the months before (13) turned age (14).

Please let us know right away if:

  • (15) did not work all months in the year; or

  • (16) earnings were not evenly spaced throughout the year.

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (3)

Full Retirement Age (FRA) - using the choices below

Choice 1

65

Choice 2

65 and 2 months

Choice 3

65 and 4 months

Choice 4

65 and 6 months

Choice 5

65 and 8 months

Choice 6

65 and 10 months

Choice 7

66

Choice 8

66 and 2 months

Choice 9

66 and 4 months

Choice 10

66 and 6 months

Choice 11

66 and 8 months

Choice 12

66 and 10 months

Choice 13

67

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (6)

Total earnings in the format $$$$$$$.¢¢

Fill-in (7)

Full Retirement Age (FRA) year in the format CCYY

Fill-in (8)

Number of months prior to the Full Retirement Age (FRA) month

Fill-in (9)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (10)

Full Retirement Age (FRA) - using the choices below

Choice 1

65

Choice 2

65 and 2 months

Choice 3

65 and 4 months

Choice 4

65 and 6 months

Choice 5

65 and 8 months

Choice 6

65 and 10 months

Choice 7

66

Choice 8

66 and 2 months

Choice 9

66 and 4 months

Choice 10

66 and 6 months

Choice 11

66 and 8 months

Choice 12

66 and 10 months

Choice 13

67

Fill-in (11)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (12)

Total earnings in the format $$$$$$$.¢¢

Fill-in (13)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (14)

Full Retirement Age (FRA) - using the choices below

Choice 1

65

Choice 2

65 and 2 months

Choice 3

65 and 4 months

Choice 4

65 and 6 months

Choice 5

65 and 8 months

Choice 6

65 and 10 months

Choice 7

66

Choice 8

66 and 2 months

Choice 9

66 and 4 months

Choice 10

66 and 6 months

Choice 11

66 and 8 months

Choice 12

66 and 10 months

Choice 13

67

Fill-in (15)

 

Choice 1

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

Choice 2

you

Fill-in (16)

 

Choice 1

his

Choice 2

her

Choice 3

your

ERN026 – EFFECT OF THE BENEFICIARY'S PRIOR YEAR EARNINGS ON THE CURRENT FULL RETIREMENT AGE (FRA) YEAR BENEFITS

Based on (1) earnings of (2) last year, we expected (3) to earn over the earnings limit of (4) this year. Therefore, we withheld some of (5) benefits. However, if (6) (7) earned less than the earnings limit of (8), (9) due full benefits for all of this year.

Please contact us if you think (10) due Social Security payments for months before (11). You will have to give us an estimate of (12) earnings for the year. Read below to find out how to estimate earnings:

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

Amount of reported earnings (AORE) for the year prior to the Full Retirement Age (FRA) year in the format $$$$$.¢¢

Fill-in (3)

 

Choice 2

him

Choice 3

her

Choice 3

you

Fill-in (4)

Full Retirement Age (FRA) year annual exempt amount in the format $$$$$.¢¢

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (6)

 

Choice 1

"from" plus Start date in Month CCYY format plus "through" plus Full Retirement Age (FRA) month minus 1 month in Month CCYY format

Choice 2

"in" plus Start Date in Month CCYY format

Fill-in (7)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (8)

Full Retirement Age (FRA) year annual exempt amount in the format $$$$$.¢¢

Fill-in (9)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (10)

 

Choice 1

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

Choice 2

you are

Fill-in (11)

Full Retirement Age (FRA) in the format Month CCYY

Fill-in (12)

 

Choice 1

his

Choice 2

her

Choice 3

your

NL 00730.130 "O" Paragraphs and Captions

A. "ONS" Paragraphs and Captions

ONS003 – EXPLANATION TO THE DISABLED ADULT CHILD WHEN HE OR SHE BECAME ENTITLED TO DISABILITY BENEFITS

We found that (1) became disabled under our rules on (2).

Fill-in values:

 

Fill-in (1)

 

Choice 1

you

Choice 2

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

Fill-in (2)

Date of entitlement

B. "OPT" Paragraphs and Captions

OPTC01 – CAPTION

Overpayment Information

OPT029 – NEW OVERPAYMENT – OVERPAYMENT NOT DUE TO TERMINATION

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

you

Fill-in (2)

Sum of the Monthly Benefit Credited (MBCs) on the Pre-MBR starting with the internal Business Start Date and ending with Current Operating Month (COM) minus 1 month in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

Internal Business Start Date in format Month CCYY

Choice 2

Internal Business Start Date plus “and” plus Current Operating Month (COM) minus 1 month in the format Month CCYY

Choice 3

Internal Business Start Date plus “through” plus Current Operating Month (COM) minus 1 month in the format Month CCYY

Fill-in (4)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (5)

Sum of the Monthly Benefit Credited (MBCs) on the Pre-MBR starting with the internal Business Start Date and ending with Current Operating Month (COM) minus 1 month in the format $$$$$.¢¢

Fill-in (6)

 

Choice 1

Internal Business Start Date in format Month CCYY

Choice 2

Internal Business Start Date plus “and” plus Current Operating Month (COM) minus 1 month in the format Month CCYY

Choice 3

Internal Business Start Date plus “through” plus Current Operating Month (COM) minus 1 month in the format Month CCYY

Fill-in (7)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (8)

Difference between Trigger Record New Overpayment Amount (TR-NEW-OPA-AMOUNT) and total Trigger Record Other Beneficiary Overpayment Amount (TR-OTH-BENE-OPA) in the format $$$$$.¢¢

Fill-in (9)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (10)

 

Choice 1

was

Choice 2

were

OPT064 – EXPLAINS TO A WORKING BENEFICIARY THERE IS AN OVERPAYMENT ON HIS OR HER RECORD FOR ONE YEAR BECAUSE THE EARNINGS THEY REPORTED IS DIFFERENT FROM WHAT SSA RECORDS SHOW

We recently found that the earnings (1) for (2) and the earnings information we have do not match. (3) told us (4) earned (5) in (6) but our records show that (7) earned (8). If our records are correct, we paid (9) (10) too much.

Fill-in values

 

Fill-in (1)

 

Choice 1

”reported for” plus Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)

Choice 2

“reported for you”

Fill-in (2)

Year in the format CCYY

Fill-in (3)

 

Choice 1

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

Choice 2

You

Fill-in (4)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (5)

Amount of reported earnings (AORE)

Fill-in (6)

Year of Earnings Report (YOER) in the format CCYY

Fill-in (7)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (8)

Amount of reported earnings (AORE)

Fill-in (9)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (10)

Overpayment amount

OPT065 – EXPLAINS TO A WORKING BENEFICIARY THAT BECAUSE THE EARNINGS PREVIOUSLY POSTED FOR MULTIPLE YEARS ARE LESS THAN THE EARNINGS ON THE MASTER EARNINGS RECORD, THERE ARE OVERPAYMENTS FOR MULTIPLE YEARS

We recently found that the earnings reported for (1) for the years shown below and the earnings on our records do not match. If our records are correct, we paid (2) (3) too much.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

you

Fill-in (2)

 

Choice 1

you

Choice 2

him

Choice 3

her

Fill-in (3)

Overpayment amount in the format $$$$$.¢¢

OPT084 – EXPLAINS TO A WORKING BENEFICIARY THAT BECAUSE THE EARNINGS PREVIOUSLY POSTED FOR A SINGLE YEAR ARE LESS THAN THE EARNINGS ON THE MASTER EARNINGS RECORD AND NO BENEFITS WERE WITHHELD FOR THIS YEAR, THERE IS AN OVERPAYMENT FOR JUST ONE YEAR

Our records show that (1) had earnings in (2) of (3) that we did not consider when we paid (4). If our records are correct, we paid (5) (6) too much.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

you

Fill-in (2)

Year of Earnings Report (YOER) in the format CCYY

Fill-in (3)

Amount of reported earnings (AORE)

Fill-in (4)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (5)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (6)

Overpayment amount

OPT085 – TELLS THE BENEFICIARY THE OVERPAYMENT AMOUNT

(1), (2) us (3).

Fill-in values:

 

Fill-in (1)

 

Choice 1

After all the changes (use when earnings caused more than 1 adjustment)

Choice 2

As a result (use when earnings caused a single adjustment)

Fill-in (2)

 

Choice 1

you owe

Choice 2

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

Fill-in (3)

Total overpayment amount due in $$$$$.¢¢ format

OPT086 – EARNINGS PREVIOUSLY POSTED FOR MULTIPLE YEARS ARE LESS THAN THE EARNINGS ON THE MASTER RECORD AND NO BENEFITS WERE WITHHELD, THEREFORE, THERE ARE OVERPAYMENTS FOR EACH YEAR

Our records show that (1) had earnings for the years shown below that we did not consider when we paid (2). If our records are correct, we paid (3) (4) too much.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

you

Fill-in (2)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (3)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (4)

Total overpayment amount

OPT087 – CHART HEADING UTI THAT PROVIDES THE WORKING BENEFICIARY THE EARNINGS POSTED WITH NO BENEFITS PREVIOUSLY WITHHELD FOR THAT YEAR EARNINGS

Earnings On

Year Our Records

OPT088 – EXPLAINS TO A WORKING BENEFICIARY IN A CHART THE EARNINGS POSTED WHEN NO BENEFITS WERE PREVIOUSLY WITHHELD FOR THESE EARNINGS

(1) (2)

Fill-in values:

 

Fill-in (1)

Year of Earnings Report (YOER) in format CCYY

Fill-in (2)

Amount of reported earnings (AORE)

OPT096 – PRIOR OVERPAYMENT WITH A PROTEST AND PROTEST DECISION STILL PENDING

We already told you that we paid (1) (2) too much for a past period. We will send you another letter to let you know what we will do about the recovery of that money.

Fill-in values

 

Fill-in (1)

 

Choice 1

you

Choice 2

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

Fill-in (2)

 

Choice 1

Due process overpayment amount in the format $$$$$.¢¢

Choice 2

Null

OPT097 – RECOVERY OF AN INCORRECT PAYMENT

Once we get back the money (1) not due for this year, we will start to withhold (2) benefits to get back the other money (3).

Fill-in values

 

Fill-in (1)

 

Choice 1

you were

Choice 2

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

Fill-in (2)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (3)

 

Choice 1

you owe

Choice 2

he owes

Choice 3

she owes

OPT107 – FULL OR PARTIAL WITHHOLDING FOR ONE MONTH

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)

 

Choice 1

Overpayment amount

Choice 2

Null

Fill-in (2)

 

Choice 1

from

Choice 2

Null

Fill-in (3)

 

Choice 1

your

Choice 4

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

Fill-in (4)

Recovery of the overpayment date in the format Month CCYY

Fill-in (5)

 

Choice 1

overpaid

Choice 2

incorrectly paid

Fill-in (6)

 

Choice 1

you

Choice 2

him

Choice 3

her

Fill-in (7)

Date the overpayment will be deducted in the format Month DD, CCYY

OPT122 – NEW OVERPAYMENT DUE TO RETROACTIVE TERMINATION

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

Current Operating Month (COM) in format Month CCYY

Fill-in (3)

 

Choice 1

he was

Choice 2

she was

Choice 3

you were

Fill-in (4)

New overpayment amount in $$$$$.¢¢

OPT123 – TOTAL OVERPAYMENT INCLUDES PRIOR OVERPAYMENT

(1) total overpayment of (2) includes (3) prior overpayment.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

Your

Fill-in (2)

Due Process Overpayment (DPO) on the Post-MBR in format $$$$$.¢¢

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

OPT125 – BENEFICIARY'S OVERPAYMENT BEING RECOVERED FROM ANOTHER AUXILIARY

We paid other person(s) on this record (1) more in benefits than we should have. Under Social Security law, you are responsible for this overpayment.

Fill-in values:

 

Fill-in (1)

Other beneficiary's overpayment amount in format $$$$$.¢¢

OPT127 – ADVISES OF OVERPAYMENT RECOVERY AMOUNT (OPRA) ON POST-MBR

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

Fill-in values:

 

Fill-in (1)

Overpayment Recovery Amount (OPRA) on post-MBR in format $$$$$$.¢¢

Fill-in (2)

 

Choice 1

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

Choice 2

your

Fill-in (3)

 

Choice 1

all

Choice 2

part

OPT128 – BENEFICIARY’S NEW OVERPAYMENT, BENEFICIARY’S PRIOR OVERPAYMENT AND ANOTHER BENEFICIARY’S OVERPAYMENT

(1) total overpayment of (2) includes (3) prior overpayment and another beneficiary's overpayment that (4) (5) liable for under Social Security law.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Fill-in (2)

Due Process Overpayment (DPO) amount on the post-MBR in format $$$$$.¢¢

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (5)

 

Choice 1

is

Choice 2

are

OPT131 – REMAINING BALANCE ON PRIOR OVERPAYMENT

(1) (2) an outstanding balance remaining on a prior overpayment. That remaining balance is (3).

Fill-in values:

Fill-in (1)
Choice 1 Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
Choice 2 You
Fill-in (2)
Choice 1 has
Choice 2 have

Fill-in (3)

Show the remaining overpayment amount or the old overpayment amount in format $$$$$$.¢¢

OPT132 – PIC A (H) DIES OR PIC B DIES AND HAVE JOINT BANK DATA ON MBR AND THERE IS AN OVERPAYMENT

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)

 

Choice 1

New overpayment amount

Fill-in (2)

 

Choice 1

NH-FULL name (possessive) when PIC A died and PIC B is responsible for the overpayment

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) when PIC B died and PIC A is responsible for the overpayment

Fill-in (3)

 

Choice 1

Beneficiary's date of death when Beneficiary Date of Death (BDOD) = Current Operating Month (COM) minus 1 month

Choice 2

Beneficiary's date of death plus “and” plus the Current Operating Month (COM) minus 1 month when the Beneficiary Date of Death (BDOD) = Current Operating Month (COM) minus 2 months

Choice 3

Beneficiary's date of death plus “through” plus Current Operating Month (COM) minus 1 month when the Beneficiary Date of Death (BDOD) > Current Operating Month (COM) minus 2 months

Fill-in (4)

Choice 1

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

Choice 2

you

Fill-in (5)

 

Choice 1

Beneficiary Date of Death (BDOD) for PIC A in the format Month CCYY

Choice 2

Beneficiary Date of Death (BDOD) for PIC B in the format Month CCYY

Fill-in (6)

 

Choice 1

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

Choice 2

you are

Fill-in (7)

 

Choice 1

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

Choice 2

you are

Fill-in (8)

 

Choice 1

Trigger Record New Overpayment Amount (WS-TR-NEW-OPA) in the format $$$$$.¢¢

Choice 2

Trigger Record Other Beneficiary Overpayment Amount (WS-TR-OTH-BENE-OPA) for WS-TR-OTH-OPA-BIC = A or WS-TR-OTH-BENE-OPA-BIC = B in the format $$$$$.¢¢

OPT133 – BENEFICIARY(S) DIE AND OVERPAYMENT RECOVERED FROM ANOTHER ENTITLED BENEFICIARY

We paid you (1) more in benefits than we should have. The overpayment occurred because we did not stop (2) benefits for (3). We can't pay benefits for the month of death, (4), or later.

Fill-in values:

 

Fill-in (1)

 

Choice 1

New overpayment amount

Choice 2

If more than one dead beneficiary is overpaid and overpayments are being recovered from another entitled beneficiary, then show the total amount of all overpaid beneficiaries

Fill-in (2)

 

Choice 1

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) for one overpaid beneficiary

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) plus “and” for two overpaid beneficiaries followed by the Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) for the second overpaid beneficiary

Choice 3

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) followed by a comma followed by Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) for the second overpaid beneficiary plus “and” followed by Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) for the third overpaid beneficiary

NOTE: If more than three dead beneficiaries with the same BDOD and overpaid, then an Incomplete notice will be generate (see Incomplete Notices under the Completion Code section for the CODE and more information)

Fill-in (3)

 

Choice 1

Beneficiary's date of death when Beneficiary Date of Death (BDOD) = Current Operating Month (COM) minus 1 month

Choice 2

Beneficiary's date of death plus “and” plus the Current Operating Month (COM) minus 1 month when the BDOD = COM minus 2 months

Choice 3

Beneficiary's date of death plus “through” plus COM minus 1 month when the Beneficiary Date of Death (BDOD) > Current Operating Month (COM) minus 2 months

Fill-in (4)

Beneficiary Date of Death (BDOD)

OPT147 – DUE PROCESS TITLE II OVERPAYMENT RECOVERY LESS THAN FULL MONTHLY BENEFIT AMOUNT

We plan to recover this overpayment (1) the payment (2) would normally receive about (3).

Fill-in values:

 

Fill-in (1)

 

Choice 1

from

Choice 2

by withholding

Fill-in (2)

 

Choice 1

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

Choice 2

you

Fill-in (3)

Overpayment recovery date in Month DD, CCYY format

OPT148 – TITLE XVI (SSI) UNDERPAYMENT USED TO REDUCE OR RECOVERY A TITLE II OVERPAYMENT (CROSS PROGRAM RECOVERY PHASE 3)

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

Fill-in values:

 

Fill-in (1)

Deductions Additions History Amount (DAH-AMOUNT) that corresponds to the Deductions Additions History Type of Payment Code (DAH-TOP) = P and Deductions Additions History Item Code (DAH-ITEM) = 382 in the format $$$$$$.¢¢

Fill-in (2)

 

Choice 1

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

Choice 2

your

OPT149 – TITLE XVI (SSI) UNDERPAYMENT NOT USED TO REDUCE OR RECOVERY A TITLE II OVERPAYMENT (CROSS PROGRAM RECOVERY PHASE 3)

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

Choice 2

your

OPT216 – OVERPAYMENT CAUSED BY SUBSTANTIAL GAINFUL WORK ACTIVITY (SGA) DURING THE EXTENDED PERIOD OF ELIGIBILITY (EPE) OR DISABILITY CESSATION DUE TO SGA

(1) received (2) too much in benefits because of (3) work activity. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

Choice 1

your

Choice 2

his

Choice 3

her

Choice 4

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

Fill-in (4)

Choice 1

your

Choice 2

his

Choice 3

her

OPT217 – OVERPAYMENT ESTABLISHED VIA CROSS PROGRAM RECOVERY (CPR) TO RECOVER A TITLE VIII SPECIAL VETERANS BENEFITS (SVB) PAID IN EXCESS

(1) received (2) too much in Special Veterans Benefit (SVB) payments. Please read the rest of this letter carefully. In it, we explain the changes we made to (3) benefits.

Fill-in values:

Fill-in (1)

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

Choice 1

your

Choice 2

his

Choice 3

her

OPT218 – OVERPAYMENT CAUSED DUE TO INCORRECT PAYMENTS FOR MEDICARE SERVICES

(1) received (2) too much in benefits because of incorrect payments for Medicare services. Please read the rest of this letter carefully. In it, we explain the changes we made to (3) benefits.

Fill-in values:

Fill-in (1)

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT219 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFCIARY WAS CONVICTED OF A CRIME OR IMPRISONED FOR MORE THAN 30 DAYS DUE TO FELONIOUS HOMICIDE

(1) received (2) too much in benefits because (3) criminal conviction and imprisonment for more than 30 days. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

Fill-in (1)

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (4)

Choice 1

your

Choice 2

his

Choice 3

her

OPT220 – OVERPAYMENT CAUSED BY WINDFALL OFFSET

(1) received (2) too much in benefits because (3) received Supplemental Security Income (SSI) payments (4) (5). Please read the rest of this letter carefully. In it, we explain the changes we made to (6) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

Choice 1

from

Choice 2

in

Fill-in (5)

Choice 1

Month CCYY through Month CCYY

Choice 2

Month CCYY

Fill-in (5)

Choice 1

your

Choice 2

his

Choice 3

her

OPT221 – OVERPAYMENT ESTABLISHED BECAUSE MORE THAN ONE PAYMENT WAS CASHED FOR THE SAME MONTH

(1) received (2) too much in benefits because we should not have paid two payments for the same month(s). Please read the rest of this letter carefully. In it, we explain the changes we made to (3) benefits.

Fill-in values:

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT222 – OVERPAYMENT ESTABLISHED DUE TO INVALID FAMILY RELATIONSHIPS

(1) received (2) too much in benefits because (3) did not meet the relationship requirements to receive benefits. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT223 – OVERPAYMENT ESTABLISHED BECAUSE OF INVALID ENTITLEMENT

(1) received (2) too much in benefits because (3) did not qualify for benefits. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT224 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY WAS DEPORTED

(1) received (2) too much in benefits because (3) deported from the United States. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you were

Choice 2

he was

Choice 3

she was

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT225 – OVERPAYMENT ESTABLISHED DUE TO INCORRECT COMPUTATION, A LEGALLY DEFINED OVERPAYMENT OR TO RECOVER A SKELETON DUE PROCESS OVERPAYMENT

(1) received (2) too much in benefits because the payment amount was incorrect. We corrected (3) record, which caused (4) benefit amount to decrease. Please read the rest of this letter carefully. In it, we explain the changes we made to (5) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (5)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT226 – OVERPAYMENT ESTABLISHED DUE TO SUBVERSIVE ACTIVITY

(1) received (2) too much in benefits because (3) convicted of a crime against the United States. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you were

Choice 2

he was

Choice 3

she was

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT227 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY DID NOT HAVE A CHILD IN THEIR CARE

(1) received (2) too much in benefits because (3) a child in (4) care who receives benefits from us. Please read the rest of this letter carefully. In it, we explain the changes we made to (5) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you no longer have

Choice 2

he no longer has

Choice 3

she no longer has

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (5)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT229 – OVERPAYMENT ESTABLISHED BECAUSE A WARRANT FOR THE BENEFICIARY’S ARREST EXISTS

(1) received (2) too much in benefits. We should not have paid (3) because of a warrant for (4) arrest. Please read the rest of this letter carefully. In it, we explain the changes we made to (5) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you

Choice 2

him

Choice 3

her

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (5)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT230 – OVERPAYMENT ESTABLISHED BECAUSE OF STATE OR FEDERAL ASSISTANCE

(1) received (2) too much in benefits because (3) received State or Federal assistance. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT231 – OVERPAYMENT CAUSED BY REPRESENTATIVE PAYEE MISUSE OF BENEFITS

(1) received (2) too much in benefits because (3) misused funds while acting as a representative payee. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT232 – OVERPAYMENT CAUSED BY DISABILITY CESSATION

(1) received (2) too much in benefits because we cannot pay benefits after (3) disability ends. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

Choice 4

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

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT234 – OVERPAYMENT ESTABLISHED DUE TO RECEIPT OF PROVISIONAL BENEFITS ON A CLAIM THAT WAS LATER DENIED

(1) received (2) too much in benefits because (3) you received temporary benefits while we were making a decision on (4) claim that we later denied. Please read the rest of this letter carefully. In it, we explain the changes we made to (5) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (5)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT235 – OVERPAYMENT ESTABLISHED DUE TO CROSS-BENEFIT ADJUSTMENT

We moved (1) overpayment of (2) to (3) for collection. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

another person's

Choice 2

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

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you

Choice 2

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

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT236 – OVERPAYMENT ESTABLISHED DUE TO CHANGE IN THE AMOUNT OR COMMENCEMENT OF THE GOVERNMENT PENSION OFFSET

(1) received (2) too much in benefits because we must offset (3) benefit payments due to (4) receipt of a government pension. Please read the rest of this letter carefully. In it, we explain the changes we made to (5) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (5)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT237 – OVERPAYMENT ESTABLISHED DUE TO RECEIPT OF A PENSION BASED ON WORK NOT COVERED BY SOCIAL SECURITY TAXES

(1) received (2) too much in benefits because (3) received a pension based on work not covered by Social Security taxes. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill -in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Choice 4

Wage Earner’s Name

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT238 – OVERPAYMENT ESTABLISHED DUE TO RECEIPT OF PAYMENTS AFTER CONFINEMENT TO A MENTAL INSTITUTION BECAUSE OF A COURT ORDER

(1) received (2) too much in benefits because (3) received payments after being confined to an institution because of a court order. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT239 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY WAS AN ALIEN LIVING OUTSIDE THE UNITED STATES WHILE RECEIVING BENEFITS

(1) received (2) too much in benefits because (3) not a United States citizen and (4) outside the country for six months in a row. Please read the rest of this letter carefully. In it, we explain the changes we made to (5) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you are

Choice 2

he is

Choice 3

she is

Fill-in (4)

 

Choice 1

you were

Choice 2

he was

Choice 3

she was

Fill-in (5)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT240 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY WORKED OUTSIDE THE US IN A JOB NOT COVERED UNDER SOCIAL SECURITY TAXES

(1) received (2) too much in benefits because (3) worked outside the United States in a job not covered by United States Social Security taxes. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT241 – OVERPAYMENT ESTABLISHED DUE TO PRISONER SUSPENSION

(1) received (2) too much in benefits because of (3) criminal conviction and confinement in a correctional institution for more than 30 days. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT242 – OVERPAYMENT ESTABLISHED DUE TO DEATH RECLAMATION, REPRESENTATIVE PAYEE ELECTRONIC FUNDS TRANSFER (EFT) AFTER DEATH OR REPRESENTATIVE PAYEE DEATH

(1) received (2) too much in benefits because we cannot pay benefits for the month of death or later. Please read the rest of this letter carefully. In it, we explain the changes we made to (3) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT243 – OVERPAYMENT ESTABLISHED DUE TO PERMANENT DEDUCTIONS RESULTING FROM THE ANNUAL EARNINGS TEST

(1) received (2) too much in benefits because of (3) work and earnings. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT244 – OVERPAYMENT ESTABLISHED DUE TO DEATH SUPER-ENDORSEMENT

(1) received (2) too much in benefits because (3) signed and cashed a check for the month of death or later . Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT245 – OVERPAYMENT ESTABLISHED DUE TO A CHANGE IN MARITAL STATUS

(1) received (2) too much in benefits because of a change in (3) marital status. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT246 – OVERPAYMENT ESTABLISHED DUE TO ENTITLEMENT TO WORKERS’ COMPENSATION, PUBLIC DISABILITY OR BOTH

(1) received (2) too much in benefits because of (3) receipt of workers’ compensation, public disability payments or both of these payments. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT247 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY CONTINUED TO RECEIVE BENEFITS AFTER THE AGE OF 18

(1) received (2) too much in benefits because we do not pay benefits once a student reaches age 18, unless he or she is a full time student elementary or high school student. Please read the rest of this letter carefully. In it, we explain the changes we made to (3) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT248 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY CONTINUED TO RECEIVE BENEFITS AFTER AGE 19 OR 22

(1) received (2) too much in benefits because we do not pay benefits once a full-time student reaches age 19, unless (3) disabled or meet(s) an exception which allows benefits to continue:

  • for 2 months after a student turns 19, or;

  • until the end of the school term, whichever comes first.

Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you are

Choice 2

he is

Choice 3

she is

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT249 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY IS NO LONGER IN FULL-TIME SCHOOL ATTENDANCE

(1) received (2) too much in benefits because we do not pay benefits once a student stops going to school full-time. Please read the rest of this letter carefully. In it, we explain the changes we made to (3) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT250 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY REFUSED TO ACCEPT VOCATIONAL REHABILITATION

(1) received (2) too much in benefits because we should not have paid benefits when (3) refused vocational rehabilitation services. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT252 – OVERPAYMENT ESTABLISHED DUE TO UNPAID ATTORNEY FEES

(1) received (2) too much in benefits because of unpaid attorney’s fees. Please read the rest of this letter carefully. In it, we explain the changes we made to (3) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT253 – OVERPAYMENT ESTABLISHED RAILROAD RETIREMENT BOARD EARNINGS WERE INCORRECTLY USED TO ESTABLISH THE BENEFICARY’S ENTITLEMENT

(1) received (2) too much in benefits because (3) received incorrect payments from the Railroad Retirement Board. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT254 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICARY WAS NOT A UNITED STATES (U.S.) CITIZEN OR LAWFULLY PRESENT IN THE U.S.

(1) received (2) too much in benefits because (3) received payments even though (4) not a United States citizen or lawfully present in the U.S. Please read the rest of this letter carefully. In it, we explain the changes we made to (5) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

you were

Choice 2

he was

Choice 3

she was

Fill-in (5)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT255 – OVERPAYMENT ESTABLISHED BECAUSE THE MONTH OF ENTITLEMENT WAS INCORRECT

(1) received (2) too much in benefits because of a change in the month (3) benefits started. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT257 – OVERPAYMENT ESTABLISHED DUE TO MULTIPLE ENTITLEMENTS

(1) received (2) too much in benefits because (3) received payments on two or more records for the same month(s). Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT258 – OVERPAYMENT ESTABLISHED BECAUSE INSURED STATUS WAS NOT MET

(1) received (2) too much in benefits because (3) worked long enough under Social Security to receive monthly benefits. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you have not

Choice 2

he has not

Choice 3

she has not

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT259 – OVERPAYMENT ESTABLISHED BECAUSE THE BENFICIARY MISUSED FUNDS WHILE SERVING AS A REPRESENTATIVE PAYEE

(1) received (2) too much in benefits because (3) misused benefits that (4) received as the representative payee for another person. Please read the rest of this letter carefully. In it, we explain the changes we made to (5) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (5)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT302 – OVERPAYMENT TRANSFERRED FROM ANOTHER RECORD FOR A DUALLY ENTITLED BENEFICIARY

We have determined that (1) (2) overpaid (3) on another record. We will recover this overpayment on this record.

Fill-in values:

 

Fill-in (1)

 

Choice 1

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Choice 2

you

Fill-in (2)

 

Choice 1

is

Choice 2

are

Fill-in (3)

Overpayment amount in the format $$$$$.¢¢

NL 00730.136 “R” Paragraphs and Captions

List of “R” Paragraphs and Captions

A. RCY Universal Text Identifiers - Recovery

RCYC01 – CAPTION

How to Pay Us Back

RCYC04 – CAPTION

Do You Think That You Do Not Owe This Money?

RCYC05 – CAPTION

Reduction To Collect Your SSI Overpayment

RCY002 – CROSS PROGRAM RECOVERY FOR SUPPLEMENTAL SECURITY INCOME (SSI) OVERPAYMENT

We paid (1) more in Supplemental Security Income (SSI) payments in the past than (2) due. Our records show that (3) us (4) in SSI payments. By law, we can collect SSI overpayments from the Social Security benefits that (5). We withheld (6) from (7) Social Security benefits to collect (8) the SSI payments that (9).

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

you

Fill-in (2)

 

Choice 1

he was

Choice 2

she was

Choice 3

you were

Fill-in (3)

 

Choice 1

he still owes

Choice 2

she still owes

Choice 3

you still owe

Fill-in (4)

Cross Program Recovery Overpayment Amount (CPR-OPAMT) in the format $$$$$$.¢¢

Fill-in (5)

 

Choice 1

he receives

Choice 2

she receives

Choice 3

you receive

Fill-in (6)

Cross Program Recovery Underpayment Amount (CPR-UPAMT) in the format $$$$$$.¢¢

Fill-in (7)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (8)

 

Choice 1

some of

Choice 2

Null

Fill-in (9)

 

Choice 1

he owes

Choice 2

she owes

Choice 3

you owe

RCY003 – CROSS PROGRAM RECOVERY FOR SUPPLEMENTAL SECURITY INCOME (SSI) OVERPAYMENT - USED WITH RCY002

You may ask us to review our finding that you still owe the money. You may have evidence to show that you already paid some or all of the money or that we previously waived collection of it. If so, give us this evidence when you ask for review. We will review the evidence you give us and the information we have. We will send you a letter with our decision. If we find that you do not owe us this amount, then we will correct our records.

For more information on requesting review, see "If You Disagree With The Decision" below.

RCY006 – BENEFITS RAISED - PARTIAL RECOVERY ENDS

We have raised (1) benefits back to (2) regular monthly payment amount. This is because (3) repaid the overpayment money (4) owed us.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

Beneficiary Given Name (BGN) (possessive)

Choice 3

your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

 

Choice 1

he

Choice 2

she

Choice 3

you

RCY007 – PARTIAL RECOVERY ENDS - NO REMAINING OVERPAYMENT

We are withholding (1) from (2) benefits. This is the remaining balance (3) owed on (4) overpayment.

Fill-in values:

 

Fill-in (1)

Monthly Recovery Amount (MRA) on the pre-MBR in the format $$$$

Fill-in (2)

 

Choice 1

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

Choice 2

your

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

B. “REF” Universal Text Identifiers – Referral

REFC01 – CAPTION

Suspect Social Security Fraud?

Please visit http://oig.ssa.gov/r or call the Inspector General’s Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).

If You Have Questions

REF001 – REFERRAL FOR DOMESTIC ADDRESS

We invite you to visit our website at www.socialsecurity.gov on the Internet to find general information about Social Security. However, if you have any specific (1) questions, you can call us at 1-800-772-1213. We can answer most questions over the phone. If you are deaf or hard of hearing, you may call out TTY number, 1-800-325-0778. You can also write or visit any Social Security office. The office that serves your area is located at:

(2)

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

Fill-in values:

 

Fill-in (1)

Null

Fill-in (2)

field office address

REF003 – REFERRAL FOR DOMESTIC ADDRESS

We invite you to visit our website at www.socialsecurity.gov on the Internet to find general information about Social Security. If you have any specific questions, you may call us toll-free at 1-800-772-1213, or call your local Social Security office at (1). We can answer most questions over the phone. If you are deaf or hard of hearing, you may call our TTY number, 1-800-325-0778. You can also write or visit any Social Security office. The office that serves your area is located at:

(2)

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

 

Fill-in (1)

local field office telephone number in format 1-XXX-XXX-XXXX

Fill-in (2)

field office address

REF008 – FIELD OFFICE REFERRAL - DEFAULT

We invite you to visit our website at www.socialsecurity.gov on the Internet to find general information about Social Security. If you have any specific (1) questions, call us toll-free at 1-800-772-1213. We can answer most questions over the phone. If you prefer to visit one of our offices, please check the local telephone directory for the office nearest you. Or call us and we can give you the office address. Please have this letter with you if you call or visit an office. It will help us answer your questions.

Fill-in values:

 

Fill-in (1)

Null

REF018 – STATE BUY-IN/BUY-OUT REFERRAL FOR DOMESTIC ADDRESS

(1)

If you have any questions (2) you may call us toll-free at 1-800-772-1213, or call your local Social Security office at (3). We can answer most questions over the phone. You can also write or visit any Social Security office. The office that serves your area is located at:

(4)

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

If you have any questions about the State Medicaid Program, please contact your State public assistance office.

Choice 2

If you have any questions about the State retirement system, please contact that office

Choice 3

Null

Fill-in (2)

about Medicare

Fill-in (3)

local Social Security office telephone number, in format, 1-XXX-XXX-XXXX

Fill-in (4)

use the street address, City, State and zip code corresponding to the MBR District Office Code (DOC)

REF020 – DEFERRAL - ADVANCE FILE MATURING

To make sure (*F1) the correct amount of benefits, you need to promptly report any changes in the amount (*F2) or (*F3) to earn. You should also report any other changes that may affect (*F4) payment.

The pamphlet (*F5) describes the events you need to report. If you no longer have the pamphlet, you can get one from our website at (*F6), or you may contact (*F7)

Please be sure to include (*F8) Social Security claim number if you do write. If you visit an office, please take this letter with you.

Fill-in values:

 

Fill-in (1)

 

Choice 1

you get

Choice 2

Beneficiary's Given Name (BGN) plus Beneficiary's Last Name (BLN) plus "gets"

Fill-in (2)

 

Choice 1

you earn

Choice 2

he earns

Choice 3

she earns

Fill-in (3)

 

Choice 1

expect

Choice 2

expects

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (5)

 

Choice 1

SSA Pub 05-10137, Your Payments While You Are Outside The United States

Choice 2

SSA Pub 05-10153, What You Need To Know When You Get Social Security Disability Benefits

Choice

3

SSA Pub 05-10077, What You Need To Know When You Get Retirement or Survivors Benefits

Fill-in (6)

www.ssa.gov

Fill-in (7)

 

Choice 1

your nearest Social Security office

Choice 2

the Social Security office that services your area in Canada. To find out which office services your area, visit www.ssa.gov/foreign/canada.htm

Choice 3

your nearest Federal Benefits Unit (FBU). Visit www.ssa.gov/foreign/foreign.htm for a list of FBUs. If you prefer you may write to the Social Security Administration at: P.O. Box 17769, Baltimore, MD 21235-7769 USA

Fill-in (8)

 

Choice 1

your

Choice 2

his

Choice 3

her

REF056 – REFERRAL - RAILROAD RETIREMENT

If you have any questions, 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.

 

REF185 – REFERRAL FOR FOREIGN ADDRESS

Visit our website at (1) to find general information about Social Security.

If you are in the United States, American Samoa, Guam, Northern Mariana Islands, Puerto Rico, or the U.S. Virgin Islands:

  • Call us toll-free at 800-772-1213 (TTY 800-325-0778 ).

  • Contact your nearest Social Security office.

If you are outside the United States or its territories:

  • If you are in Canada, visit (2) to find the office that services your area.

  • Contact your nearest Federal Benefits Unit (FBU). Visit (3) for a list of FBUs.

  • Write to the Social Security Administration at:

P.O. Box 1776

Baltimore, Maryland 21235-7769

USA

Please be sure to include (4) 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 (5) for information.

Fill-in values:

 

Fill-in (1)

www.ssa.gov

Fill-in (2)

www.ssa.gov/foreign/canada.htm
Fill-in (3)

www.ssa.gov/foreign/foreign.htm

Fill-in (4)
Choice 1 your
Choice 2 his
Choice 3 her
Fill-in (5) Medicare.gov

C. REP Universal Text Identifiers – Claimant Representation

REPC01 – CAPTION

If You Want Help With Your Appeal

REP002 – APPEALS INFORMATION - NOT USED ON END-STAGE RENAL DISEASE (ESRD) TERMINATION NOTICE

You may choose to have a representative help you. We will work with this person just as we would work with you. If you decide to have a representative, you should find one quickly so that person can start preparing your case.

Many representatives charge a fee only if you receive benefits. Others may represent you for free. Usually, your representative may not charge a fee unless we approve it. Your local Social Security office can give you a list of groups that can help you find a representative.

If you get a representative, you or that person must notify us in writing. You may use our Form SSA-1696 “Appointment of Representative.” Any local Social Security office can give you this form.

REP005 – APPEALS INFORMATION FOR AN END-STAGE RENAL DISEASE (ESRD) TERMINATION NOTICE

You can have a friend, lawyer, or someone else help you. There are groups that can help you find a lawyer or give you free legal services if you qualify. There are also lawyers who do not charge unless you win your appeal. Your Social Security office has a list of groups that can help you with your appeal. If you get someone to help you, you should let us know.

D. RFU Universal Text Identifiers - Refund

R FU001 – OVERPAYMENT REQUESTED FROM TERMINATED BENEFICIARY

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)

Overpayment amount in the format $$$$$$.¢¢

Fill-in (2)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in ( 3 )

Overpayment amount in the format $$$$$$.¢¢

RFU002 – OVERPAYMENT REQUESTED - FOREIGN ADDRESS

If (1) 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 (2) us in local currency, we use the exchange rates in effect at the time we get (3) payment. If this causes a difference between the amount (4) us and the amount (6) us, we will let you know. If you cannot mail your payment to us, please contact your nearest Federal Benefits Unit (FBU). Visit (7) for a list of FBUs. If you are in Canada, visit (8) to find the office that services your area. They will help you make the refund.

Fill-in values:

 

Fill-in (1)

 

Choice 1 you pay
Choice 2 he pays
Choice 3 she pays

Fill-in (2)

 

Choice 1

you pay

Choice 2

he pays

Choice 3

she pays

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3 her

Fill-in (4)

 

Choice 1 you pay
Choice 2 he pays
Choice 3 she pays

Fill-in (5)

 

Choice 1 you owe
Choice 2 he owes
Choice 3 she owes

Fill-in (6)

Choice 1

your

Choice 2

his

Choice 3 her

Fill-in (7)

www.ssa.gov/foreign/foreign.htm

Fill-in (8)

www.ssa.gov/foreign/canada.htm

RFU004 – SUPPLEMENTAL SECURITY INCOME (SSI) IS DETERMINED AND SOCIAL SECURITY RETROACTIVE BENEFITS ARE GREATER THAN THE SSI WINDFALL OFFSET AMOUNT

We compared (1) Social Security and SSI benefits. We found we should have paid (2) (3) less in SSI benefits. We will withhold this amount from (4) Social Security benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

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

Fill-in (2)

 

Choice 1

you

Choice 2

him

Choice 3

her

Choice 4

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

Fill-in (3)

Deductions Additions History Amount (DAH-AMOUNT) that corresponds to the Deductions Additions History Type of Payment (DAH-TOP) = PMA (P) and Deductions Additions History Item (DAH-ITEM) = 345 (DIB SSI offset) or the DAH ITEM = 346 (RIB SSI offset) in the format $$$$$$.¢¢

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

RFU006 – SUPPLEMENTAL SECURITY INCOME (SSI) IS DETERMINED AND THE SOCIAL SECURITY RETROACTIVE BENEFITS ARE LESS OR EQUAL TO THE WINDFALL OFFSET AMOUNT

We compared (1) Social Security and SSI benefits. We found that we should have paid (2) (3) less SSI benefits. As a result, we cannot pay (4) any of the Social Security benefits we withheld.

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

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

Fill-in (2)

 

Choice 1

you

Choice 2

him

Choice 3

her

Choice 4

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

Fill-in (3)

Deductions Additions History Amount (DAH-AMOUNT) that corresponds to the Deductions Additions History Type of Payment Code (DAH-TOP) = PMA (P) and [Deductions Additions History Item Code (DAH-ITEM) = 345 (DIB SSI offset or DAH-ITEM=346 (RIB SSI offset)] in the format $$$$$$.¢¢.

Fill-in (4)

 

Choice 1

you

Choice 2

him

Choice 3

her

Choice 4

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

RFU007 – SUPPLEMENTAL SECURITY INCOME (SSI) WINDFALL OFFSET IS DETERMINED AND THERE IS NO SSI OFFSET APPLIED TO SECURITY BENEFITS THEREFORE RETRO BENEFITS ARE PAYABLE TO THE BENEFICIARY

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

you

Choice 2

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

Fill-in (2)

 

Choice 1

History Start date of the first month where Reason for Suspension = WINFAL in the format Month CCYY

Choice 2

Start date that corresponds to the Reason for Suspension = WINFAL plus ”through” plus the stop date of the last WINFAL Suspension month

RFU012 – TITLE II OVERPAYMENT ADJUSTMENT FROM BENEFITS WHEN OVERPAYMENT AMOUNT IS GREATER THAN MONTHLY BENEFIT AMOUNT (MBA)

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)

Overpayment amount due in format $$$$$$.¢¢

Fill-in (2)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (4)

 

Choice 1

Null

Choice 2

for him

Choice 3

for her

Fill-in (5)

Date of payment in the format Month DD, CCYY

Fill-in (6)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (7)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (8)

 

Choice 1

your

Choice 2

his

Choice 3

her

E. RIN Universal Text Identifiers – Rate Information

RIN006 – EXPLAINS ADJUSTMENT REDUCTION FACTOR INCREASE

Because (1) retired early, we reduced (2) monthly Social Security benefit. The amount that we reduced it was based on the number of months (3) would receive benefits before (4). However, (5) didn't receive benefits some of these months because (6) worked and earned over certain limits. So, we must increase (7) benefit amount to give credit for these months.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

you

Fill-in (2)

 

Choice 1

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

Choice 2

his

Choice 3

her

Choice 4

your

Fill-in (3)

 

Choice 1

Beneficiary Given Name (BGN)

Choice 2

he

Choice 3

she

Choice 4

you

Fill-in (4)

 

Choice 1

full retirement age

Choice 2

age 62

Choice 3

age 60

Fill-in (5)

 

Choice 1

Beneficiary Given Name (BGN)

Choice 2

he

Choice 3

she

Choice 4

you

Fill-in (6)

 

Choice 1

Beneficiary Given Name (BGN)

Choice 2

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

Choice 3

he

Choice 4

she

Choice 5

you

Choice 6

he and his spouse

Choice 7

she and her spouse

Choice 8

you and your spouse

Choice 9

his spouse

Choice 10

her spouse

Fill-in (7)

 

Choice 1

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

Choice 2

his

Choice 3

her

Choice 4

your

RIN007 – EXPLAINS DELAYED RETIREMENT CREDIT INCREASE

When (1) filed for Social Security benefits, we figured the benefit amount based on (2) earnings history at that time. If after becoming entitled to benefits, (3) to work, (4) may earn credit for this additional work. So, we must increase (5) benefit amount to give credit for these months.

We apply the increase sometime after it is due. This is because earnings information is not available until after each tax year.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

you

Fill-in (2)

 

Choice 2

his

Choice 3

her

Choice 4

your

Fill-in (3)

 

Choice 1

he continues to work or later returns

Choice 2

she continues to work or later returns

Choice 3

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) plus “continues to work or later returns”

Choice 4

you continue to work or later return

Fill-in (4)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

RIN008 – MONTHLY BENEFIT AMOUNT (MBA) CHANGE - ANOTHER BENEFICIARY IS TERMINATED OR BECOMES ENTITLED ON THE RECORD

We changed (1) monthly benefit to (2) starting (3). We made this change because we (4) paying benefits to another person on this record.

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

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

Fill-in (2)

 

Choice 1

Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of the MBA increase

Choice 2

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

Fill-in (3)

 

Choice 1

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

Choice 2

 

NA-HIST-START month in the format Month CCYY

Fill-in (4)

 

Choice 1

started

Choice 2

stopped

RIN012 – MONTHLY BENEFIT AMOUNT (MBA) CHANGE - COST OF LIVING INCREASE

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of the MBA decrease

Choice 2

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

Fill-in (3)

 

Choice 1

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

Choice 2

NA-HIST-START month in the format Month CCYY

RIN013 – AUXILIARY'S MONTHLY BENEFIT AMOUNT (MBA) CHANGE DUE TO ANOTHER BENEFICIARY'S DEATH

We changed (1) monthly benefit to (2) starting (3). We changed (4) benefit because of the death of (5).

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of the MBA increase

Choice 2

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

Fill-in (3)

 

Choice 1

Effective Date (EFD) on the post-MBR associated with the Monthly Benefit Amount (MBA) increase due to death

Choice 2

NA-HIST-START month in the format Month CCYY

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

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

Choice 2

another person entitled on this record

RIN044 – AUXILIARY MONTHLY BENEFIT AMOUNT (MBA) CHANGE - ANOTHER BENEFICIARY ENTITLED AND COST-OF-LIVING ADJUSTMENT (COLA)

We changed (1) monthly benefit to (2) beginning (3) because we started paying another person(s) on this record. This change also includes the cost of living increase.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

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

Choice 2

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

Fill-in (3)

 

Choice 1

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

Choice 2

NA-HIST-START month in the format Month CCYY

RIN045 – MONTHLY BENEFIT AMOUNT (MBA) CHANGE - ANOTHER BENEFICIARY TERMINATES AND COST-OF-LIVING ADJUSTMENT (COST-OF-LIVING ADJUSTMENT (COLA))

We changed (1) monthly benefit to (2) beginning (3) because benefits to another entitled person(s) stopped. This change also includes the cost of living increase.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

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

Choice 2

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

Fill-in (3)

 

Choice 1

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

Choice 2

NA-HIST-START month in the format Month CCYY

RIN046 – NUMBER HOLDER NOTICE WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFIT (PDB) INVERSE OFFSET POSTPONED MONTHLY BENEFIT AMOUNT (MBA) CHANGE

We changed (1) monthly benefit to (2) beginning (3).

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

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

Fill-in (3)

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

RIN047 – MONTHLY BENEFIT AMOUNT (MBA) CHANGE - AGE REDUCTION FACTOR (ARF)

We changed (1) monthly benefit to (2) starting (3). We gave (4) credit for benefits that we did not pay at the full rate before (5) reached (6).

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

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

Choice 2

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

Fill-in (3)

 

Choice 1

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

Choice 2

NA-HIST-START month in the format Month CCYY

Fill-in (4)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (5)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (6)

 

Choice 1

age 60

Choice 2

age 62

Choice 3

full retirement age

RIN048 – MONTHLY BENEFIT AMOUNT (MBA) CHANGE - DELAYED RETIREMENT CREDIT (DRC)

We raised (1) monthly benefit amount beginning (2) to (3). We changed (4) benefit amount to give (5) credit for the past months that (6) delayed receiving retirement benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

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

Fill-in (2)

 

Choice 1

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

Choice 2

TDA-RETAP-EVENT-DATE that corresponds to the TDA-EVENT-INDICATOR = A602 in the format Month CCYY

Fill-in (3)

 

Choice 1

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

Choice 2

TDA-RETAP-EVENT-DATE that corresponds with TDA-EVENT-INDICATOR = A602 in the format $$$$$.¢¢

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (5)

 

Choice 1

you

Choice 2

him

Choice 3

her

Fill-in (6)

 

Choice 1

you

Choice 2

he

Choice 3

she

RIN049 – MONTHLY BENEFIT AMOUNT (MBA) CHANGE DUE TO INCORRECT MBA

We changed (1) monthly benefit to (2) as of (3). We found that (4) prior amount was incorrect.

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

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

Fill-in (2)

 

Choice 1

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

Choice 2

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

Fill-in (3)

 

Choice 1

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

Choice 2

NA-HIST-START month in the format Month CCYY

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

RIN053 – MONTHLY BENEFIT AMOUNT (MBA) CHANGE DUE TO DUAL ENTITLEMENT (BENEFITS COMBINED OR DECOMBINED)

We changed (1) monthly benefit amount to (2) starting (3). We changed the amount because (4) also entitled on another record.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

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

Fill-in (3)

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

Fill-in (4)

 

Choice 1

you are

Choice 2

he is

Choice 3

she is

RIN059 – PRIMARY INSURANCE AMOUNT (PIA) CHANGE DUE TO CREDITABLE MILITARY SERVICE

We are changing (1) benefits to give (2) credit for time (3) spent in military service. This time was not included when we figured (4) benefit before.

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

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

Choice 3

his

Choice 4

her

Fill-in (2)

 

Choice 1

you

Choice 2

him

Choice 3

her

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

RIN060 – IDENTIFIES SPECIFIC YEAR(S) OF EARNINGS CREDITED TO THE NUMBER HOLDER, RESULTING IN A PRIMARY INSURANCE AMOUNT (PIA) INCREASE

We changed (1) benefit amount to give (2) credit for (3) (4) earnings. We did not include these earnings when we figured (5) benefit amount before.

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

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

Choice 3

his

Choice 4

her

Fill-in (2)

 

Choice 1

you

Choice 2

him

Choice 3

her

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (4)

 

Choice 1

Year of earnings in format CCYY

Choice 2

Year of earnings and year of earnings in format CCYY and CCYY

Choice 3

 

 

Year of earnings, year of earnings and year of earnings in format CCYY, CCYY and CCYY

Choice 4

Year of earnings, year of earnings, year of earnings and year of earnings in format CCYY, CCYY, CCYY and CCYY

Choice 5

Null

Fill-in (5)

 

Choice 1

your

Choice 2

his

Choice 3

her

RIN061 – DUALLY ENTITLED BENEFICIARY RECEIVING PRIMARY INSURANCE AMOUNT (PIA) INCREASE ON THE OTHER RECORD – NO INCREASE DUE ON OWN PIA

We reviewed our records to see if (1) due more money. We increased (2) benefits to give (3) credit for the earnings of (4) spouse that we did not count before.

Fill-in values:

 

Fill-in (1)

 

Choice 1

you are

Choice 2

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

Choice 3

he is

Choice 4

she is

Fill-in (2)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (3)

 

Choice 1

you

Choice 2

him

Choice 3

her

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

RIN062 – DUALLY ENTITLED BENEFICIARY RECEIVING PRIMARY INSURANCE AMOUNT (PIA) INCREASE ON OWN ACCOUNT – BENEFITS ON OTHER RECORD ARE ENDING BECAUSE BENEFICIARY’S OWN BENEFIT IS LARGER

We reviewed our records and found that we can increase (1) benefits. We increased (2) benefits because we gave (3) credit for earnings that we did not count before.

(4) benefits on (5) own record and as a (6) on another record. Since (7) benefits are now higher on (8) own record, we stopped the benefits (9) on the other record.

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

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

Choice 3

his

Choice 4

her

Fill-in (2)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (3)

 

Choice 1

you

Choice 2

him

Choice 3

her

Fill-in (4)

 

Choice 1

You receive

Choice 2

He receives

Choice 3

She receives

Fill-in (5)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (6)

 

Choice 1

spouse

Choice 2

parent

Choice 3

surviving spouse

Choice 4

divorced spouse

Choice 5

surviving former spouse

Fill-in (7)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (8)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (9)

 

Choice 1

you receive

Choice 2

he receives

Choice 3

she receives

RIN063 – DUALLY ENTITLED BENEFICIARY’S ONGOING MONTHLY PAYMENT AMOUNT REMAINS THE SAME OR IS SLIGHTLY DIFFERENT DUE TO ROUNDING – SMALLER PRIMARY INSURANCE AMOUNT (PIA) AND BENEFIT INCREASE ON OWN RECORD WHILE LARGER PIA ON OTHER RECORD REMAINS THE SAME BUT THE AMOUNT PAYABLE DECREASES

Since we increased the amount we pay (1) on (2) own record, we decreased the amount we pay (3) on another record.

Fill-in values:

 

Fill-in (1)

 

Choice 1

you

Choice 2

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

Choice 3

him

Choice 4

her

Fill-in (2)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (3)

 

Choice 1

you

Choice 2

him

Choice 3

her

RIN064 – DUALLY ENTITLED BENEFICIARY RECEIVES PRIMARY INSURANCE AMOUNT (PIA) INCREASE ON OWN RECORD AND ON THE OTHER RECORD

We increased the benefits on both Social Security records. To get the amount we can pay (1), we subtract the new benefit on (2) own record from the new benefit on the other record.

Fill-in values:

 

Fill-in (1)

 

Choice 1

you

Choice 2

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

Choice 3

him

Choice 4

her

Fill-in (2)

 

Choice 1

your

Choice 2

his

Choice 3

her

RIN065 – DUALLY ENTITLED BENEFICIARY RECEIVES PRIMARY INSURANCE AMOUNT (PIA) INCREASE ON OWN ACCOUNT – ONGOING MONTHLY PAYMENT AMOUNT REMAINS THE SAME OR IS SLIGHTLY DIFFERENT DUE TO ROUNDING – SMALLER PIA AND BENEFIT INCREASE ON OWN ACCOUNT WHILE LARGER PIA ON OTHER RECORD REMAINS THE SAME BUT AMOUNT PAYABLE DECREASES

Since we increased the amount we pay (1) on (2) own record, we decreased the amount we pay (3) on (4) spouse’s record.

Fill-in values:

 

Fill-in (1)

 

Choice 1

you

Choice 2

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

Choice 3

him

Choice 4

her

Fill-in (2)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (3)

 

Choice 1

you

Choice 2

him

Choice 3

her

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

RIN066 – MONTHLY BENEFIT AMOUNT (MBA) DECREASED BECAUSE ACTUAL EARNINGS WERE LESS THAN THE EXPECTED EARNINGS ORIGINALLY USED TO CALCULATE THE PRIMARY INSURANCE AMOUNT (PIA)

We reviewed (1) record and found that (2) earnings changed. These changes caused (3) monthly benefit amount to decrease effective (4).

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

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

Fill-in (2)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (4)

 

Choice 1

 

Post-MBR History Effective Date (EFD) associated with the first Primary Insurance Amount Effective Date (PIED) occurrence of Primary Insurance Amount (PIA) decrease in the format Month CCYY

F. RPA Universal Text Identifier – Representative Payee Annual Accounting

RPAC01 – CAPTION

It Is Important To Keep Track Of This Money

G. RPY Universal Text Identifiers – Representative Payee

RPY002 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF PAYEE DEVELOPMENT (DEVPYE) OR DEATH OF PAYEE (DTHPYE)

If you know someone who can be your payee, please call us at either of the telephone numbers shown at the end of this letter. We will consider this person for your new payee. Also, if you believe you are able to manage your own money, please let us know. Call us within the next 30 days if you do not hear from us. You may be able to get some payments directly while we make our decision.

RPY003 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF PAYEE DEVELOPMENT (DEVPYE) OR DEATH OF PAYEE (DTHPYE)

If you know someone who can be your payee, please call us at either of the telephone numbers shown at the end of this letter. We will consider this person for your payee. Also, call us within the next 30 days if you do not hear from us. You may be able to keep getting some payments directly while we make our decision.

RPY015 – FORMER PAYEE NOTICE

Thank you for your willingness to serve as a representative payee. We have decided that it would be best for (1) to have (2) checks sent to another payee.

Fill-in values:

 

Fill-in (1)

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

Fill-in (2)

 

Choice 1

his

Choice 2

her

RPY016 – FORMER PAYEE NOTICE

We have decided that it would be best for (1) to have (2) checks sent to (3).

Fill-in values:

 

Fill-in (1)

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

Fill-in (2)

 

Choice 1

his

Choice 2

her

Fill-in (3)

 

Choice 1

him

Choice 2

her

RPY038 – PAYEE CHANGE TO SELF

We will begin to send your checks directly to you. The rest of this letter will give you more information about your benefits.

RPY039 – NEW PAYEE SELECTED

We have chosen you to be (1) representative payee. The rest of this letter will give you information about the checks you will receive while you are the payee.

Fill-in values:

 

Fill-in (1)

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

RPY041 – NEW PAYEE SELECTED

Please read the enclosed pamphlet, “A Guide for Representative Payees.” It lists the things you will need to know because you have been chosen as payee.

RPY042 – NEW PAYEE SELECTED

You will need to keep track of how you use all of the money we send you for (1). Each year we will ask you to report on how you used the money. We call this a representative payee accounting.

Fill-in values:

 

Fill-in (1)

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

RPY048 – NEW PAYEE SELECTED - NO BENEFITS PAYABLE

We have chosen you to be (1) representative payee. However, we cannot pay benefits at this time.

Fill-in values:

 

Fill-in (1)

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

RPY073 – PAYEE CHANGE - BENEFICIARY'S NOTICE

We have chosen (1) to be your representative payee. Your payee will receive your checks each month and will use this money for your needs.

Fill-in values:

 

Fill-in (1)

New Payee Name

RPY086 – BENEFICIARY DIES - PAYEE TOLD ABOUT CONSERVED FUNDS

You may have saved some Social Security money for (1). Any money that you have saved, plus any interest on that money, belongs to (2) estate.

Fill-in values:

 

 

Fill-in (1)

BGN plus BLN

Fill-in (2)

 

Choice 1

his

Choice 2

her

RPY087 – BENEFICIARY DIES - PAYEE TOLD OF DISPOSITION OF FUNDS

You need to do one of these things:

  • Give this money to the legal representative of the estate, or

  • If there is no legal representative, contact the state probate court. They will be able to tell you what to do with the money, or

  • If there is no legal representative, and you live outside the United States, contact the authorities who control the estate's money. They will be able to tell you what to do with the money.

H. RRB Universal Text Identifier – Railroad Board

RRBC01 – CAPTION

What The Railroad Retirement Board Will Do

I. RSD Universal Text Identifier – Not Qualified For Medicare

RSD003 – MEDICARE DISALLOWANCE - RESIDENCY

(1) cannot qualify for Medicare because (2) did not live in any of the 50 states, the District of Columbia, the Commonwealth of Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa or the Northern Mariana Islands at the time (3) applied for Medicare.

Fill-in values:

 

Fill-in (1)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (2)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you


NL 00730 TN 36 - Title II Redesign (T2R) Notices Title II Postentitlement (PE) Actions - 9/23/2021