Identification Number:
NL 00720 TN 16
Intended Audience:See Transmittal Sheet
Originating Office:DCO OES
Title:Manual Adjustment, Credit and Award Process (MADCAP) Beneficiary Notice Print Program
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 20 – Manual Adjustment, Credit and Award Process (MADCAP) Beneficiary Notice Print Program
Transmittal No. 16, 12/11/2020

Audience

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

Originating Component

OEIS

Effective Date

Upon Receipt

Background

We are updating Program Operations Manual System (POMS) sections in NL 00720 effective with Manual Adjustment Credit and Award Data Entry System (MADCAP) August 28, 2020 release. The language changes and updates for notices in the attached sections are a direct result of updates requested by the Office of Income Security Programs (OISP). These changes were in support of the Veterans Administration Regional Office (VARO) clearance package and ATY UTI clearance package changes.

Summary of Changes

NL 00720.007 List of Captions for MADCAP

Updating section info with new language,

NL 00720.010 Paragraph Sequence by Caption

Updating section info with new language

NL 00720.050 ATY Representative Fee

We updated the text in the caption Universal Text Identifiers (UTIs) ATYC01 and ATYC03 to reflect the word Representatives and Representative to accommodate changes made to ATY captions because of the ATY clearance package. Additionally, we updated the language for ATYR15 that include revising fill-in 1 and removing fill-ins 2 through 6.

We updated MADCAP UTIs ATY016, ATY065, ATY066, and ATY071 because the attorney user fee has increased from $97.00 to $98.00.

 

NL 00720.095 CLO Closeout

We revised UTI CLOR05 by including adding "lump sum death payment" as an additional and choice fill-in for fill-in 1 and fill-in 4.

 

NL 00720.280 REF Referral

We updated to reflect the replacement of the UTI REF002 with REF185

 

NL 00720.295 RFU Refund

We revised the language for UTI RFU020.

NL 00720.007 List of Captions for MADCAP

CAPTION TEXT

TNA/ AURORA UTI

A PENALTY WILL BE DEDUCTED FROM PAYMENTS

PENC02

ABOUT THE APPEALS

ALSC26

BENEFIT OFFSET NATIONAL DEMONSTRATION (BOND)

DIBC12

DO YOU THINK THAT YOU DO NOT OWE THIS MONEY?

RCYC02

DO YOU THINK WE ARE WRONG ABOUT THE OVERPAYMENT?

ALSC06

DO YOU THINK WE ARE WRONG?

ALSC01

HEALTH INSURANCE FOR CHILDREN

HIBC02

HOW THE HEARING PROCESS WORKS

ALSC05

HOW TO ASK US TO REVIEW THE DETERMINATION ON THE FEE AGREEMENT

ATYC02

HOW TO ASK US TO REVIEW THE FEE

ATYC05

HOW TO PAY US BACK

RCYC01

HOW TO PAY US BACK

OPTC05

IF YOU ASK FOR A RECONSIDERATION AND A HEARING

ALSC28

IF YOU DISAGREE WITH THE COURT ORDER

GARC01

IF YOU DISAGREE WITH THE DECISIONS

ALSC04

IF YOU HAVE ANY QUESTIONS

REFC01

IF YOU HAVE QUESTIONS ABOUT THE BOND PROJECT

REFC05

IF YOU HAVE QUESTIONS THAT ARE NOT ABOUT THE BOND PROJECT

REFC06

IF YOU SAVE ANY MONEY

CFDC02

IF YOU THINK YOU SHOULD NOT HAVE TO PAY US BACK

WAVC01

IF YOU WANT HELP WITH YOUR APPEAL

REPC01

IF YOU WANT TO APPEAL

ALSC27

INFORMATION ABOUT HEALTH PLAN AND PRESCRIPTION DRUG PLAN COSTS

MHPC04

INFORMATION ABOUT HEALTH PLAN PREMIUMS

MHPC02

INFORMATION ABOUT REPRESENTATIVES FEES

ATYC01

INFORMATION ABOUT MEDICARE

HIBC01

INFORMATION ABOUT MEDICARE PRESCRIPTION DRUG PLAN COSTS

MHPC03

INFORMATION ABOUT MILITARY SERVICE

MSVC01

INFORMATION ABOUT OTHER DISABILITY BENEFITS

DIBC09

INFORMATION ABOUT PAST-DUE BENEFITS WITHHELD TO PAY A REPRESENTATIVE

ATYC03

INFORMATION ABOUT THE CLARK COURT CASE

FUGC06

INFORMATION ABOUT THE MARTINEZ SETTLEMENT

FUGC05

INFORMATION ABOUT THE PRESCRIPTION DRUG COVERAGE INCOME-RELATED MONTHLY ADJUSTMENT AMOUNT

MPDC31

INFORMATION ABOUT WORK AND EARNINGS

ERNC09

INFORMATION ABOUT YOUR INSTALLMENT PAYMENT

ASTC02

INFORMATION WE NEED FROM YOU

SUSC04

IT IS IMPORTANT TO GO TO THE HEARING

ALSC08

OTHER INFORMATION

COPC01

OTHER SOCIAL SECURITY BENEFITS

CLOC01

PRESCRIPTION DRUG PLAN ENROLLMENT

MPDC19

REDUCTION TO COLLECT YOUR SSI OVERPAYMENT

RCYC05

RULES FOR LAWFUL PRESENCE IN THE U.S.

INFC09

RULES UNDER THE NEW LAW

RNSC02

THE BASIS FOR OUR DECISION

DIBC02

THE DATE YOU BECAME DISABLED

DIBC01

THINGS TO REMEMBER

INFC08

WE CONSIDERED FOREIGN CREDITS

TOTC01

WHAT HAPPENS WHEN THE SPECIAL RULES FOR BOND NO LONGER APPLY

INFC50

WHAT WE WILL PAY

PAYC38

WHAT WE WILL PAY AND WHEN

PAYC01

WHAT YOU NEED TO DO

INFC06

WHEN PROVISIONAL BENEFITS END

XRPC01

WHEN WE BEGIN YOUR PAYMENTS

CHKC11

WHY WE ARE DELAYING YOUR PAYMENTS

CHKC03

WHY WE BEGIN YOUR PAYMENTS

PAYC39

WHY WE CANNOT PAY YOU

CHKC01

WHY YOUR BENEFITS ENDED

BENC17

WHY YOUR PROVISIONAL BENEFITS ENDED

XRPC02

YOU MAY BE DUE MORE BENEFITS

AETC02

YOUR BENEFITS

CHKC09

YOUR RESPONSIBILITIES

INFC02

YOUR SSI PAYMENTS MAY CHANGE

ATYC04

NL 00720.010 Paragraph Sequence by Caption

A. Introduction to the Manual Adjustment, Credit, and Award Process (MADCAP) notice system

The MADCAP notice system prints each generated or requested Universal Text Identifier (UTI) according to a pre-determined sequence under the appropriate caption.

B. Sequence chart

The sequence chart in this section shows the paragraph order for the MADCAP Notices.

Attorney Copies

GROUP 2 (Adjustments)

GROUP 3 (Adjustments)

COP002

 

 

COP014

 

 

LIS004

LIS004

AWD013

RPY015

OPT158

AET064

CFDC02

ERN086

HIB198

CFD003

ERN087

DIB002

RCYC01

ERN046

AWD011

CFD004

RNS031

BEN089

REFC07

XRP001

ENT027

REF001

RNS032

RRB001

REF008

RNS033

RPY039

REF185

INF130

AWD012

REF003

AET064

DTH012

 

TER039

DID001

 

XRP018

BEN090

 

XRP008

XRP001

 

TER016

FUGC05

 

TER040

FUG104

 

OPT161

FUG105

 

OPT163

FUG106

 

OPT164

RNSC02

 

BEN090

RNS033

 

FUGC05

CHKC03

 

FUG104

SUS026

 

FUG105

INFC06

 

FUG106

RPY003

 

XRPC02

SUS063

 

XRP006

CHKC11

 

XRP012

SUS021

 

XRP009

INFC09

 

RNSC02

SUS065

 

RNS033

SUS064

 

CHKC03

SUS057

 

SUS026

PAYC38

 

INFC06

XRP002

 

RPY003

ADJ024

 

CHKC11

ADJ025

 

SUS021

PAY161

 

CHKC09

OCO001

 

INS001

ADJ020

 

ENT071

PAY032

 

ADJ027

BEV018

 

ADJ028

ADJ054

 

ADJ029

ADJ055

 

ADJ032

ADJ046

 

ADJ035

ADJ047

 

ADJ037

PMT001

 

ADJ038

SSI066

 

ADJ039

WFO003

 

RIN048

SSI067

 

ADJ041

ATY059

 

ADJ050

ATY060

 

ADJ051

ADJ021

 

ADJ052

ADJ058

 

ADJ053

ADJ048

 

ADJ043

ADJ049

 

ADJ044

OPT149

 

ADJ045

DTH011

 

OPT159

ENT063

 

AWD014

ENT064

 

AWD016

PAYB15

 

HIB188

DTH009

 

ADJ023

DTH010

 

ENT056

LSP013

 

BEN080

ENT067

 

BEN081

PAY067

 

ENT038

PAY068

 

BEN031

PAY072

 

SUS006

PAY073

 

BEN086

BEN084

 

SUS095

LVY022

 

SUS087

GAR003

 

SUS094

GAR064

 

SUS014

LVY038

 

SUS001

LVY023

 

SUS040

GAR004

 

FOB012

PAY176

 

SUS056

CHKC09

 

SUS077

ADJ050

 

SUS084

ENT071

 

SUS099

FOBR21

 

SUS100

BEN087

 

PRI015

MISR02

 

PRI014

FOBR21

 

PRI006

BEN087

 

PRI029

MISR02

 

PRI030

MISR03

 

PRIR01

MISR04

 

FUG058

PAY212

 

PRI049

WDW005

 

FUG059

SEIR02

 

FUG060

SEIR03

 

FUG061

SEIR04

 

FUG031

ERN038

 

FUG063

SEIR06

 

FUG064

SEIR07

 

FUG065

ERNR09

 

SUS211

ERNR10

 

BEN102

ERNR11

 

TER043

ERN039

 

TER001

MSVR06

 

TER002

INS018

 

TER010

INS001

 

TER003

CLOR20

 

TER016

INS008

 

BEN050

INS002

 

TER041

INS003

 

TER042

INS004

 

TER044

INS005

 

TER045

INS007

 

TER046

INS006

 

TER048

INS017

 

TER049

AWD014

 

CICR11

TAX027

 

ERN040

RRB002

 

ERN041

ADJ023

 

WDS019

ENT056

 

WDS020

BEN080

 

WDS021

BEN081

 

ERN042

ENT038

 

ERN054

BEN031

 

ERN043

SUS006

 

ERN050

BEN086

 

ERN044

SUS095

 

ERN056

SUS087

 

OPT262

SUS094

 

OPT263

SUS014

 

OPT264

OPT148

 

OPT265

SUS001

 

OPT266

SUS040

 

OPT267

FOB012

 

OPT268

SUS056

 

OPT269

PRI015

 

OPT270

PRI014

 

OPT271

PRI006

 

OPT272

PRI029

 

OPT273

PRI030

 

OPT274

PRIR01

 

OPT275

FUG058

 

OPT276

PRI049

 

OPT277

FUG059

 

OPT278

FUG060

 

OPT279

FUG061

 

OPT280

FUG031

 

OPT281

FUG063

 

OPT282

FUG064

 

OPT283

FUG065

 

OPT284

SUS211

 

OPT285

BEN102

 

OPT286

TER043

 

OPT287

TER001

 

OPT288

TER002

 

OPT289

TER010

 

OPT290

TER003

 

OPT291

BEN050

 

OPT292

TER041

 

OPT293

TER042

 

OPT294

TER045

 

OPT295

TER046

 

OPT296

TER048

 

OPT297

TER049

 

OPT298

CICR11

 

OPT299

ERN040

 

OPT300

ERN041

 

OPT301

WDS019

 

OPT168

WDS020

 

OPT028

WDS021

 

OPT179

ERN042

 

OPT166

ERN052

 

OPT181

ERN054

 

PAY182

ERN043

 

OPT169

ERN047

 

OPT122

ERN048

 

OPT171

ERN050

 

PAY184

ERN022

 

OPT127

ERN025

 

OPT170

ERN090

 

BEN017

AET043

 

PAY181

ERN044

 

UPT010

ERN056

 

PAY183

ERN057

 

OPT167

ERN058

 

BEN032

ERN093

 

ERN049

ERN059

 

ERN071

ERN060

 

ERN077

ERN061

 

ERN080

ERN062

 

ERN047

ERN063

 

ERN048

ERN081

 

ERN022

TWPR01

 

ERN025

TWPR02

 

ERN090

ERN064

 

AET043

UPT010

 

RRB009

OPT262

 

OPT152

OPT263

 

ADJ022

OPT264

 

OPT154

OPT265

 

OPT155

OPT266

 

GAR008

OPT267

 

COA002

OPT268

 

ERN089

OPT269

 

ERN045

OPT270

 

ERN053

OPT271

 

ERN088

OPT272

 

AET035

OPT273

 

ERN082

OPT274

 

ERN069

OPT275

 

ERN072

OPT276

 

WEP001

OPT277

 

LVY026

OPT278

 

ADJ016

OPT279

 

PAYB10

OPT280

 

ADJ019

OPT281

 

RCY006

OPT282

 

RFU008

OPT283

 

RIN016

OPT284

 

ENT028

OPT285

 

ENT029

OPT286

 

BEN053

OPT287

 

BEN051

OPT288

 

BEN052

OPT289

 

AMN008

OPT290

 

ATY061

OPT291

 

RFU007

OPT292

 

AMN009

OPT293

 

SSI062

OPT294

 

AWD017

OPT295

 

PMT002

OPT296

 

PMT017

OPT297

 

PMT027

OPT298

 

PMT003

OPT299

 

TAX021

OPT300

 

TAX011

OPT301

 

TAX022

PAY181

 

TAX023

PAY182

 

ERN051

BEN104

 

ERN052

PAY183

 

ERN078

ERN049

 

ERN067

ERN071

 

WCP010

ERN077

 

WCP048

ERN080

 

WCP012

RRB009

 

WCPR13

OPT152

 

WCP018

ADJ022

 

WCPR20

OPT154

 

WCPR23

OPT155

 

WCPR24

COA002

 

WCPR25

ERN089

 

WCP050

ERN045

 

WCP051

ERN053

 

WCP052

ERN088

 

WCP053

AET035

 

ENT075

ERN082

 

WCP026

ERN069

 

WCP058

ERN072

 

WCPR15

ADJ027

 

WCP054

ADJ038

 

WCP013

ADJ032

 

WCP057

RIN048

 

WCP049

ADJ043

 

COL007

ADJ028

 

TAX050

ADJ029

 

TAX002

ADJ044

 

TAX025

ADJ035

 

TAX003

ADJ045

 

TAX024

ADJ037

 

WCP004

WEP001

 

OPT153

LVY026

 

OPT156

ADJ016

 

LVY054

PAYB10

 

TAX004

ADJ019

 

LVY055

RCY006

 

LVY056

RFU008

 

TAX019

RIN016

 

TAX020

ENT028

 

ERN083

ENT029

 

ERN079

BEN053

 

WCP055

BEN051

 

BEN077

BEN052

 

CIC002

AMN008

 

BEN076

ATY061

 

OPT132

RFU007

 

WCP019

RCY002

 

WCP015

AMN009

 

WCP017

SSI062

 

ERN065

AWD017

 

ERN066

PMT002

 

WDS002

PMT017

 

ERN073

PMT027

 

ERN076

PMT003

 

TAX026

TAX021

 

ADJ017

TAX011

 

ADJ018

TAX022

 

OPT151

ERN051

 

OPT107

ERN078

 

OPT165

ERN067

 

OPT162

WCP010

 

MOE003

WCP048

 

ENT062

WCP012

 

PEN029

WCPR13

 

PEN030

WCP018

 

ERN057

WCP019

 

ERN092

WCP015

 

ERN058

WCP017

 

ERN093

WCPR20

 

ERN059

WCPR23

 

ERN060

WCPR24

 

ERN061

WCPR25

 

ERN062

WCP050

 

ERN063

WCP051

 

ERN081

WCP052

 

TWPR01

WCP053

 

TWPR02

ENT075

 

ERN064

WCP026

 

ENT048

WCP058

 

TOT004

WCPR15

 

CIC010

WCP054

 

BEN082

WCP013

 

WIB001

WCP057

 

WIB002

WCP049

 

OPT148

COL007

 

SUS074

TAX050

 

BEN075

TAX002

 

WDW017

TAX025

 

VTW001

TAX003

 

VTW002

TAX024

 

VTW003

WCP004

 

VTW006

OPT153

 

VTW004

OPT156

 

VTW005

LVY054

 

VTW008

TAX004

 

VTW009

LVY055

 

VTW011

LVY056

 

VTW012

TAX019

 

VTW021

TAX020

 

VTW024

ERN083

 

CDR063

ERN079

 

SUS035

WCP055

 

CDR066

OPT179

 

CDR067

BEN077

 

TER010

CIC002

 

RCY002

BEN076

 

SUSC04

OPT166

 

SUS065

OPT181

 

PAYC38

OPT169

 

ADJ020

OPT171

 

PAY032

OPT122

 

ADJ024

OPT132

 

ADJ025

PAY184

 

OCO001

ERN065

 

PMT001

ERN066

 

SSI066

OPT028

 

WFO003

OPT127

 

SSI067

OPT168

 

ATY059

TAX026

 

ATY060

OPT170

 

ADJ021

ADJ017

 

DTH011

ADJ018

 

ENT063

OPT167

 

ENT064

OPT151

 

PAY180

OPT107

 

BEN100

BEN032

 

ADJ015

MOE003

 

PAY073

ENT062

 

PAYB15

PEN029

 

DTH010

PEN030

 

ENT067

WDS002

 

PAY067

ERN073

 

PAY068

ERN076

 

TAX006

ENT048

 

XRP002

TOT004

 

XRP003

CIC010

 

GAR005

BEN082

 

LVY024

GAR005

 

GAR006

VTW001

 

GAR007

VTW002

 

LVY025

VTW003

 

GAR008

VTW006

 

LVY026

VTW004

 

GAR009

VTW005

 

LVY027

VTW008

 

LVY022

VTW009

 

GAR003

VTW011

 

GAR064

VTW012

 

LVY038

VTW021

 

LVY023

VTW024

 

GAR004

WIB002

 

OPT149

CDR063

 

PAY176

SUS035

 

RCYC05

CDR066

 

RCY021

CDR067

 

WAVC01

TER010

 

WAV005

RCYC05

 

XRPC01

RCY021

 

XRP004

WAVC01

 

COPC01

WAV005

 

XRP005

XRPC01

 

BRR075

XRP004

 

BRR076

TOTC01

 

COP013

TOT009

 

COP001

DIBC01

 

AETC02

ONS004

 

ERN091

ONS002

 

INFC09

DIB003

 

SUS065

OPTC05

 

SUS064

RFU001

 

SUS057

RFU020

 

DIBC01

RFU012

 

ONS004

OPT180

 

ONS002

OPT165

 

DIB003

RFU003

 

OPTC05

ALSC06

 

RFU001

WAV001

 

RFU020

WAV002

 

RFU012

PENC02

 

OPT180

PEN001

 

OPT165

PEN024

 

RFU003

PEN025

 

ALSC06

PEN026

 

WAV001

PEN027

 

WAV002

PEN028

 

PENC02

ERN068

 

PEN001

HIBC01

 

PEN024

AGE006

 

PEN025

HIB187

 

PEN026

HIB021

 

PEN027

HIB188

 

PEN028

HIB189

 

ERN068

HIB256

 

HIBC01

HIB022

 

HIB187

HIB003

 

HIB021

HIB004

 

HIB189

HIB200

 

HIB190

HIB212

 

HIB256

ENT051

 

HIB022

HIB191

 

ENT051

ENT052

 

HIB033

HIB252

 

HIB191

HIB249

 

HIB036

MHP001

 

ENT052

MHP002

 

HIB192

MHP003

 

HIB184

MHP004

 

HIB257

MHP005

 

HIB095

HIB095

 

HIB254

HIB254

 

HIB255

HIB255

 

HIB193

HIB192

 

HIB139

HIB193

 

HIB250

HIB139

 

HIB194

HIB250

 

HIB015

HIB194

 

HIB195

HIB015

 

MHP001

HIB195

 

MHP002

MHP054

 

MHP003

HIB196

 

MHP004

HIB197

 

MHP005

HIBR60

 

HIB061

HIB190

 

HIB093

HIB199

 

HIB092

HIB011

 

MHP054

HIB039

 

HIB196

HIB217

 

HIB197

HIB218

 

HIBR60

HIB219

 

HIB252

HIB220

 

HIB249

HIB221

 

HIB039

HIB223

 

HIB217

HIB224

 

HIB218

HIB227

 

HIB219

HIB228

 

HIB220

HIB229

 

HIB221

HIB230

 

HIB223

HIB041

 

HIB224

HIB234

 

HIB227

HIB215

 

HIB228

HIB235

 

HIB229

HIB236

 

HIB230

HIB237

 

HIB041

HIB244

 

HIB234

HIB170

 

HIB215

HIB171

 

HIB045

HIB239

 

XRP007

HIB242

 

XRP013

HIB243

 

XRP010

HIB152

 

HIB236

HIB002

 

HIB237

HIB052

 

HIB244

HIB231

 

HIB170

HIB251

 

HIB171

HIB232

 

HIB239

HIB233

 

HIB243

HIB240

 

HIB242

HIB241

 

HIB002

HIB213

 

HIB152

HIB214

 

HIB052

HIB216

 

HIB231

HIB019

 

HIB251

HIB182

 

HIB232

HIB260

 

HIB233

HIB261

 

HIB240

HIB262

 

HIB241

HIB263

 

HIB213

HIB264

 

HIB214

HIB265

 

HIB216

HIB266

 

HIB019

HIB267

 

HIB040

HIB268

 

HIB043

HIB269

 

HIB182

HIB270

 

HIB260

HIB183

 

HIB261

HIB185

 

HIB262

HIB184

 

HIB263

HIB186

 

HIB264

HIB175

 

HIB265

HIB257

 

HIB266

HIB033

 

HIB267

HIB036

 

HIB268

HIB040

 

HIB269

HIB045

 

HIB270

HIB043

 

HIB183

XRP007

 

HIB185

XRP013

 

HIB186

XRP010

 

HIB175

MPDC31

 

MPDC31

MPD350

 

MPD350

MPD348

 

MPD348

MPD352

 

MPD352

MPD349

 

MPD349

MPD351

 

MPD351

ASTC02

 

ASTC02

HIB271

 

HIB271

MHPC02

 

MHPC02

MHP009

 

MHP009

MHP016

 

MHP016

MHP035

 

MHP035

MHP038

 

MHP038

MHP015

 

MHP015

HIB258

 

HIB258

MHP012

 

MHP012

MHP013

 

MHP013

MHP017

 

MHP017

MHP018

 

MHP018

MPDC19

 

MPDC19

MHP053

 

MHP053

MHPC03

 

MHPC03

MHP033

 

MHP033

MHP045

 

MHP045

MHP036

 

MHP036

MHP039

 

MHP039

MHP043

 

MHP043

MHP041

 

MHP041

MHP047

 

MHP047

MHP049

 

MHP049

MHPC04

 

MHPC04

HIB238

 

HIB238

MHP046

 

MHP046

MHP037

 

MHP037

MHP040

 

MHP040

MHP044

 

MHP044

MHP042

 

MHP042

MHP048

 

MHP048

MHP050

 

MHP050

MPD346

 

MPD346

MPD347

 

MPD347

HIBC02

 

ATYC01

HIB157

 

ATY054

ATYC01

 

ATY055

ATY054

 

ATY056

ATY055

 

ATY057

ATY056

 

ATY058

ATY057

 

ATYR03

ATY058

 

ATY800

ATYR03

 

ATY801

ATY800

 

ATY804

ATY801

 

ATYR20

ATY804

 

ATY834

ATYR20

 

ATYR02

ATY834

 

ATY069

ATYR02

 

ATY070

ATY069

 

ATYR22

ATY070

 

ATYR05

ATYR22

 

ATYR15

ATYR05

 

ATY816

ATYR15

 

ATY062

ATY816

 

ATY825

ATY062

 

ATY064

ATY825

 

ATY016

ATY064

 

ATY065

ATY031

 

ATY066

ATY016

 

ATY067

ATY065

 

ATYC04

ATY066

 

ATY063

ATY067

 

ATYC05

ATYC04

 

ATY808

ATY063

 

ATY809

ATYC05

 

ATYC02

ATY808

 

ATY817

ATY809

 

ATYC03

ATYC02

 

ATY836

ATY817

 

ATYR12

ATYC03

 

ATY068

ATY836

 

ATY838

ATYR12

 

DIBC09

ATY068

 

WCPR02

ATY838

 

WCP001

DIBC09

 

WCP003

WCPR02

 

WCP005

WCP001

 

WCPR06

WCP003

 

WCPR07

WCP005

 

WCP021

WCPR06

 

WCPR22

WCPR07

 

WCP008

WCP021

 

WCPR27

WCPR22

 

WCPR09

WCP008

 

ERNC09

WCPR27

 

AET002

WCPR09

 

ERN075

ERNC09

 

SEI006

AET002

 

ERNR09

ERN075

 

MSVC01

SEI006

 

MSV008

ERNR09

 

MSVR06

MSVC01

 

MSV001

MSV008

 

MSVR02

MSVR06

 

MSVR07

MSV001

 

DIBC02

MSVR02

 

ENT070

MSVR07

 

AGER09

DIBC02

 

BEN085

ENT070

 

DIB004

AGER09

 

DIB005

BEN085

 

CLOC01

DIB004

 

BEN078

DIB005

 

CLO029

CLOC01

 

TOT010

CLO002

 

CLOR05

CLOR11

 

ENT015

CLOR12

 

ENT065

CLOR13

 

DOA044

BEN078

 

INS021

CLO029

 

REL011

TOT010

 

CLO002

CLOR05

 

INFC02

ENT015

 

ENT068

ENT065

 

ENT069

DOA044

 

RPY041

INS021

 

AET031

REL011

 

STU001

AWD010

 

ENT001

INFC02

 

BRRR13

BRR004

 

VRN001

ENT068

 

WCP029

ENT069

 

WCP009

BEN088

 

WCPR31

BRR016

 

WCP032

RPY041

 

BRR040

STU001

 

ERN055

ENT001

 

ERN070

BRRR13

 

FWK001

VRN001

 

BRR026

WCP029

 

ALSC04

WCP009

 

ALS113

WCPR31

 

ALSC26

WCP032

 

ALS171

BRR040

 

ALSC27

ERN055

 

ALS172

ERN070

 

ALSC28

WDS019

 

ALS123

FWK001

 

ALSC05

ALSC04

 

ALS125

ALS113

 

ALSC08

ALSC26

 

ALS054

ALS171

 

INFC08

ALSC27

 

FOB005

ALS172

 

BEN083

ALSC28

 

BRR057

ALS123

 

CDR001

ALSC05

 

CDR002

ALS125

 

CDR003

ALSC08

 

BRR006

ALS054

 

WCP028

INFC08

 

CIC003

FOB005

 

CIC004

BEN083

 

CICR12

BRR057

 

PRI023

CDR001

 

BRR006

CDR002

 

TER047

CDR003

 

TER050

BRR006

 

RRB008

WCP028

 

ENT066

CIC003

 

AETR32

CIC004

 

ERN074

CICR12

 

PRI011

PRI023

 

PRI044

BRR006

 

CIC012

TER047

 

CIC013

TER050

 

CIC014

RRB008

 

CDR065

ENT066

 

SNO002

AETR32

 

SNO004

ERN074

 

GARC01

PRI011

 

GAR088

PRI044

 

ALSC01

CIC012

 

ALS023

CIC013

 

ALS185

CIC014

 

ALS046

CDR065

 

ALS186

SNO002

 

RCN021

SNO004

 

ALS170

GARC01

 

REPC01

GAR088

 

REP001

ALSC01

 

REFC01

ALS023

 

REF001

ALS185

 

REF008

ALS046

 

REF185

ALS186

 

REF003

RCN021

 

REF141

ALS170

 

REF142

REPC01

NL 00720.050 ATY Representative Fee

ATY016 DETERMINATION OF REPRESENTATIVE'S ASSESSMENT AMOUNT – NH, NH AND AUXILIARIES OR AUXILIARIES ONLY – SSA PAYING ONE REPRESENTATIVE, NO PREVIOUS ASSESSMENT (L34)

(Requested)

  • Caption: Information About Representative's Fees

We are paying the  (1)  from the benefits we withheld. Therefore, we must collect a service charge from him or her. The service charge is 6.3 percent of the fee amount we pay, but not more than $98.00, which is the most we can collect in each case under the law. We will subtract the service charge from the amount payable to the  (2)  .  (3) 

The  (4)  cannot ask you to pay for the service charge. If the  (5)  disagrees with the amount of the service charge, he or she must write to the address shown at the top of this letter. The  (6)  must tell us why he or she disagrees within 15 days from the day he or she gets this letter.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: representative
Fill-in (2) - Systems Generated
Choice 1: representative
Fill-in (3) – Systems Generated
Choice 1: After we subtract the amount we are paying towards the fee, we will send you the balance of the amount withheld.
Choice 2: Null
Fill-in (4) - Systems Generated
Choice 1: representative
Fill-in (5) - Systems Generated
Choice 1: representative
Fill-in (6) - Systems Generated
Choice 1: representative

ATY054 NO PAST-DUE BENEFITS AVAILABLE — REPRESENTATIVE INVOLVED (A56)

(Requested)

Caption: Information About Representative's Fees

When a representative wants to charge for helping with a Social Security claim, we must first approve the fee. We usually withhold 25 percent of past-due benefits in order to pay the approved representative's fee. However, there are no past-due benefits available to be paid to the representative.

If all work on this case for  (1)  and  (2)  family is finished, and  (3)  representative wants to charge a fee, a request to have it approved should be sent to us right away.

When the amount of the fee is decided, SSA is not involved in paying the fee.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's name
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

ATY055 COURT CASE ATTORNEY FEE WITHHOLDING NH ONLY (C15)

(Requested)

Caption: Information About Representative's Fees

 (1)   (2)  may ask the court to approve a fee no larger than 25 percent of past due benefits. Past due benefits are those payable through  (3)  , the month before the court's decision. For this reason, we are withholding  (4)  .

After the court sets the fee, we will let  (5)  and the  (6)  know how much of this money will be used to pay the fee. We will send any remainder to  (7)  .


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Your
Choice 2: Beneficiary's Name possessive
Fill-in (2) - Systems Generated
Choice 1: representative
Fill-in (3) - Requested As A Date In Format Shown Below MM/CCYY
Fill-in (4) - Requested As A Money Amount In Format $$$$$.¢¢
Amount of withholding
Fill-in (5) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's name
Fill-in (6) - Systems Generated
Choice 1: representative
Fill-in (7) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her

ATY056 COURT CASE ATTORNEY FEE WITHHOLDING FROM NH AND FAMILY (C16)

(Requested)

Caption: Information About Representative's Fees

 (1)   (2)  may ask the court to approve a fee no larger than 25 percent of past due benefits. Past due benefits are those payable to  (3)  and  (4)  family through  (5)  , the month before the court's decision. For this reason, we are withholding  (6)  .

After the court sets the fee, we will let  (7)  and the  (8)  know how much of this money will be used to pay the fee. We will send any remainder to  (9)  and  (10)  family.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Your
Choice 2: Beneficiary's Name possessive
Fill-in (2) - Systems Generated
Choice 1: representative
Fill-in (3) – Systems Generated
Choice 1: you
Choice 2: Beneficiary's name
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) - Requested As A Date In Format Shown Below
MM/CCYY
Fill-in (6) - Requested As A Money Amount In Format $$$$$.¢¢
Amount of withholding
Fill-in (7) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's name
Fill-in (8) - Systems Generated
Choice 1: representative
Fill-in (9) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (10) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

ATY057 NOTICE TO CLAIMANT WHERE A REPRESENTATIVE FEE HAS NOT YET BEEN AUTHORIZED (C18)

(Requested)

Caption: Information About Representative's Fees

When a  (1)  wants to charge for helping with a Social Security claim, we must first approve the fee. We usually withhold 25 percent of past due benefits in order to pay the approved  (2)  fee. We withheld  (3)  from  (4)  past due benefits in case we need to pay  (5)   (6)  .

  • If all the work on this case for  (7)  and  (8)  family is finished, and  (9)   (10)  wants to charge a fee, a request to have it approved should be sent to us right away.

  • If all work is not finished in this case, the  (11)  should let us know that a fee will be charged. This must be done within 60 days of the date of this letter.

  • If the  (12)  will not charge a fee, a statement saying so, signed and dated by the  (13)  , should be sent to us instead.

When the amount of the fee is decided, we will let  (14)  and the  (15)  know how much of this money will be used to pay the fee. We will send any remainder to  (16)  . If the approved fee is more than the money we have withheld, the Social Security Administration is not involved in paying the rest of the fee.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: representative
Fill-in (2) - Systems Generated
Choice 1: representative
Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢
Amount of withholding
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: Beneficiary's Name possessive
Fill-in (5) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (6) - Systems Generated
Choice 1: representative
Fill-in (7) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's name
Fill-in (8) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (9) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (10) - Systems Generated
Choice 1: representative
Fill-in (11) - Systems Generated
Choice 1: representative
Fill-in (12) - Systems Generated
Choice 1: representative
Fill-in (13) - Systems Generated
Choice 1: representative
Fill-in (14) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's name
Fill-in (15) - Systems Generated
Choice 1: representative
Fill-in (16) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's name

ATY058 NOTICE TO CLAIMANT AND FAMILY WHERE ATTORNEY FEE HAS NOT YET BEEN AUTHORIZED (C19)

(Requested)

Caption: Information About Representative's Fees

When a  (1)  wants to charge for helping with a Social Security claim, we must first approve the fee. We usually withhold 25 percent of past due benefits in order to pay the approved  (2)  fee. We withheld  (3)  from the past due benefits of  (4)  and  (5)  family in case we need to pay  (6)   (7)  .

  • If all the work on this case for  (8)  and  (9)  family is finished, and  (10)   (11)  wants to charge a fee, a request to have it approved should be sent to us right away.

  • If all work is not finished in this case, the  (12)  should let us know that a fee will be charged. This must be done within 60 days of the date of this letter.

  • If the  (13)  will not charge a fee, a statement saying so, signed and dated by the  (14)  , should be sent to us instead.

When the amount of that fee is decided, we will let  (15)  and the  (16)  know how much of this money will be used to pay the fee. We will send any remainder to  (17)  and  (18)  family. If the approved fee is more than the money we have withheld, the Social Security Administration is not involved in paying the rest of the fee.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: representative
Fill-in (2) - Systems Generated
Choice 1: representative's
Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢
Amount of withholding
Fill-in (4) - Systems Generated
Choice 1: you
Choice 2: Beneficiary name
Fill-in (5) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (6) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (7) - Systems Generated
Choice 1: representative
Fill-in (8) - Systems Generated
Choice 1: you
Choice 2: Beneficiary name
Fill-in (9) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (10) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (11) - Systems Generated
Choice 1: representative
Fill-in (12) - Systems Generated
Choice 1: representative
Fill-in (13) - Systems Generated
Choice 1: representative
Fill-in (14)
Fill-in (15) - Systems Generated
Choice 1: you
Choice 2: Beneficiary name
Fill-in (16) - Systems Generated
Choice 1: representative
Fill-in (17) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (18) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

ATY059 TITLE II/TITLE XVI REPRESENTATIVE FEE AGREEMENT – OFFSET INFORMATION PENDING – NH OR AUXILIARY (IES) (L12)

(Requested)

Caption: What We Will Pay

We are holding  (1)  Social Security benefits for  (2)  . We may have to reduce these benefits if  (3)  received Supplemental Security Income (SSI) for this period. We will not reduce  (4)  past-due benefits if  (5)  did not get SSI benefits for those months.

 (6) 

When we decide how much  (7)  due for this period, we will send  (8)  another letter.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your
Choice 2: Beneficiary name possessive
Full-in (2) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (3) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (6) - Requested As A One Position Alpha Character
Choice 1: (A) However, we will withhold part of any past-due benefits to pay the representative.
Choice 2: (B) Null
Fill-in (7) - Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (8) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her

ATY060 SSI OFFSET INFORMATION PENDING CRITICAL CASE FEE AGREEMENT OR FEE PETITION CASE (L13)

(Requested)

Caption: What We Will Pay

Although we are sending  (1)   (2)  of the money  (3)  due for past months, we are withholding  (4)  Social Security benefits for  (5)  . We may have to reduce these benefits if  (6)  received Supplemental Security Income (SSI) for this period. We will not reduce  (7)  past-due benefits if  (8)  did not get SSI benefits for those months.  (9) 

When we decide how much  (10)  due for this period, we will send  (11)  another letter.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you
Choice 2: Beneficiary name
Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢
Amount of payment
Fill-in (3) - Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/ CCYY through MM/ CCYY
Fill-in (6) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (7) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (8) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (9) - Requested As A One Position Alpha Character
Choice 1: (A) However, we will withhold part of any past-due benefits to pay your representative. Later in this letter, we will tell you more about the money we are withholding to pay your representative.
Choice 2: (B) However, we will withhold part of any past-due benefits to pay his representative. Later in this letter, we will tell him more about the money we are withholding to pay his representative.
Choice 3: (C) However, we will withhold part of any past-due benefits to pay her representative. Later in this letter, we will tell her more about the money we are withholding to pay her representative.
Choice 4: (D) Null
Fill-in (10) Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (11) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her

ATY061 TITLE II OFFSET APPLIED – CONCURRENT TITLE II/TITLE XVI - FEE AGREEMENT OR FEE PETITION (L22)

(Requested)

Caption: Your Benefits

In an earlier letter, we told  (1)  that we were withholding  (2)  Social Security benefits for  (3)  . We did this because we thought we might have to reduce  (4)  Social Security benefits if  (5)  also received Supplemental Security Income (SSI) money for this period.

Now we are writing to let you know that we cannot pay  (6)   (7)  of the Social Security benefits we withheld. This is because  (8)  received SSI money for  (9)  .

When you receive SSI money for a month, and later you receive Social Security benefits, we sometimes have to reduce your Social Security benefits. We do this to make sure that your total SSI and Social Security monthly payment is not more than it would have been if the Social Security benefits had been paid on time.

 (10)  past-due Social Security benefits are  (11)  for  (12)  . We usually withhold 25 percent of past-due benefits to pay a  (13)  fee. We withheld  (14)  from  (15)  past-due benefits to pay the  (16)  . We are deducting  (17)  from the  (18)  in benefits due for  (19)  . That leaves  (20)  .

Allowing for  (21)  Social Security benefits, we should have paid  (22)   (23)  less in SSI money. We have to take this out of the  (24)  .


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (6) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (7) - Requested As A One Position Alpha Character
Choice 1 (A): any
Choice 2 (B): all
Fill-in (8) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (9) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (10) - Systems Generated
Choice 1: Your
Choice 2: Beneficiary's Name possessive
Fill-in (11) - Requested As A Money Amount In Format $$$$$.¢¢
Amount of past-due benefits
Fill-in (12) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (13) - Systems Generated
Choice 1: representative's
Fill-in (14) - Requested As A Money Amount In Format $$$$$.¢¢
Attorney fee from past-due benefits
Fill-in (15) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (16) - Systems Generated
Choice 1: representative
Fill-in (17) - Requested As A One Position Alpha Character Or As A Money Amount In Format $$$$$.¢¢
Choice 1: (A) this amount
Choice 2: actual money amount being deducted
Fill-in (18) - Requested As A Money Amount In Format $$$$$.¢¢
Total amount of past-due benefits
Fill-in (19) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (20) - Requested As A Money Amount In Format $$$$$.¢¢
Balance of past-due benefits
Fill-in (21) - Systems Generated
Choice 1: your
Choice 2: Beneficiary's Name possessive
Fill-in (22) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (23) - Requested As A Money Amount In Format $$$$$.¢¢
Amount of Title II benefits that should have been withheld from SSI benefits
Fill-in (24) (Same as Fill-in 20)
Balance of past-due benefits

ATY062 FEE AGREEMENT CASE – CONCURRENT TITLE II/TITLE XVI – REPRESENTATIVE FEE BEING PAID (L23)

(Requested)

Caption: Information About Representative's Fees

We told  (1)  in another letter that the  (2)  could charge  (3)  no more than  (4)  , under the fee agreement, for his or her work on  (5)  Social Security claim. We also said,  (6)  , the  (7)  , or the person who decided  (8)  case could ask us to review the amount of the fee.

We withheld  (9)  from  (10)  benefits to pay the  (11)  . We are sending the  (12)  this money. This means we are paying the  (13)  in full for the work on your Social Security claim.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (2 ) - Systems Generated
Choice 1: representative
Fill-in (3) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (4) - Requested As A Money Amount In Format $$$$$.¢¢
Amount
Fill-in (5) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (6) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (7) - Systems Generated
Choice 1: representative
Fill-in (8) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (9) - Requested As A Money Amount In Format $$$$$.¢¢
Amount withheld
Fill-in (10) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (11) - Systems Generated
Choice 1: representative
Fill-in (12) - Systems Generated
Choice 1: representative
Fill-in (13) - Systems Generated
Choice 1: representative

ATY062 FEE AGREEMENT CASE TITLE II/TITLE XVI FEE MAY CHANGE SSI BENEFITS (Use if FO was not requested to recompute) (L24)

(Requested)

Caption: Your SSI Payments May Change

Because we approved a fee in  (1)  Social Security claim, the amount of benefits we used in figuring  (2)  SSI payments may change. Contact  (3)  local Social Security office to see if we can pay  (4)  more SSI money.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your
Choice 2: Beneficiary's Name possessive
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (4) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her

ATY064 ADDITIONAL FEE AMOUNT – SSI AWARDED – CONCURRENT TITLE II/TITLE XVI (L32)

(Requested)

Caption: Information About Representative's Fees

The  (1)  may be able to charge an additional amount for his or her work on  (2)  Supplemental Security Income (SSI) claim.  (3)  will get another letter, about SSI, telling  (4)  the additional fee amount, if any, the  (5)  can charge.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: representative
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: the
Fill-in (3) - Systems Generated
Choice 1: You
Choice 2: Beneficiary's name
Fill-in (4) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (5) - Systems Generated
Choice 1: representative

ATY065 DETERMINATION OF REPRESENTATIVE'S ASSESSMENT AMOUNT – NH, NH AND AUXILIARIES OR AUXILIARIES ONLY – SSA PAYING TWO OR MORE REPRESENTATIVES SIMULTANEOUSLY, NO PREVIOUS ASSESSMENT (L35)

(Requested)

Caption: Information About Representative's Fees

We are paying the  (1)  from the benefits we withheld. Therefore, we must collect a service charge from each of them. The service charge is 6.3 percent of the fee amount we pay, but not more than $98, which is the most we can collect in each case under the law. When 6.3 percent of the combined payments exceeds $98, we divide the $98 service charge based on the individual fee amounts. We will subtract part of the service charge from the fee amount payable to each  (2)  .  (3) 

A  (4)  cannot ask  (5)  to pay for the service charge. If a  (6)  disagrees with the amount of the service charge, he or she must write to the address shown at the top of this letter. The  (7)  must tell us why he or she disagrees within 15 days from the day he or she gets this letter.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: representatives
Fill-in (2) - Systems Generated
Choice 1: representative
Fill-in (3) - Requested As A One Position Alpha Character
Choice 1: (A) After we subtract the amount we are paying towards the fees, we will send you the balance of the amount we withheld.
Choice 2: (B) Null
Fill-in (4) - Systems Generated
Choice 1: representative
Fill-in (5) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (6) - Systems Generated
Choice 1: representative
Fill-in (7) - Systems Generated
Choice 1: representative

ATY066 DETERMINATION OF REPRESENTATIVE'S ASSESSMENT AMOUNT – NH, NH AND AUXILIARIES OR AUXILIARIES ONLY – SUBSEQUENT PAYMENT, SSA PREVIOUSLY ASSESSED LESS THAN $97 (L36)

(Requested)

Caption: Information About Representative's Fees

We are paying the  (1)  from the benefits we withheld. Therefore, we must collect a service charge from him or her. The service charge is 6.3 percent of the fee amount we pay, but not more than $98, which is the most we can collect in each case under the law. We previously paid a fee and collected  (2)  . The service charge we must collect now is  (3)  . We will subtract this service charge from the amount payable to the  (4)  .  (5)  The  (6)  cannot ask  (7)  to pay for the service charge. If the  (8)  disagrees with the amount of the service charge, he or she must write to the address shown at the top of this letter. The  (9)  must tell us why he or she disagrees within 15 days from the day he or she gets this letter.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: representative
Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢
Amount (assessment collected before)
Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢
Amount (assessment being collected now)
Fill-in (4) - Systems Generated
Choice 1: representative
Fill-in (5) - Requested As A One Position Alpha Character
Choice 1: (A) After we subtract the amount we are paying towards the fee, we will send you the balance of the amount withheld.
Choice 2: (B) NULL
Fill-in (6) - Systems Generated
Choice 1: representative
Fill-in (7) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (8) - Systems Generated
Choice 1: representative
Fill-in (9) - Systems Generated
Choice 1: representative

ATY067 APPOINTED REPRESENTATION DATA AND FEE ESTABLISHED APPOINTED REPRESENTATION DATA (L38)

(Requested)

Caption: Information About Representative's Fees

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) - Requested As A One Position Alpha Character
Choice 1: (A) lawyer
Choice 2: (B) participant in the non-attorney direct payment demonstration project
Fill-in (2) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
Fill-in (3) - Systems Generated
Choice 1: lawyer
Choice 2: participant in the demonstration project
Fill-in (4) - Systems Generated
Choice 1: Beneficiary's Name possessive
Choice 2: your
Fill-in (5) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
Fill-in (6) - Systems Generated
Choice 1: him
Choice 2 : her
Choice 3: you
Fill-in (7) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
Fill-in (8) - Systems Generated
Choice 1: representative

ATY068 REPRESENTATIVE FEE AGREEMENT – TITLE II/TITLE XVI – SSA WITHHOLDING PAST-DUE BENEFITS – NH (L14)

(Requested)

Caption: Information About Past-Due Benefits Withheld To Pay A Representative

 (1)  past-due Social Security benefits are  (2)  for  (3)  . Because of the law, we usually withhold 25 percent of the total past-due benefits or the maximum payable under the fee agreement to pay an approved  (4)  fee. We withheld  (5)  from  (6)  past-due benefits to pay the  (7)  .


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Your
Choice 2: Beneficiary's Name possessive
Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Amount
Fill-in (3) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (4) - Systems Generated
Choice 1: representative
Fill-in (5) - Requested As A Money Amount In Format $$$$$.¢¢
Amount
Fill-in (6) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (7) - Systems Generated
Choice 1: representative

ATY069 FEE AGREEMENT AMOUNT – TITLE II/TITLE XVI – OFFSET INFORMATION PENDING (L15)

(Requested)

Caption: Information About Representative's Fees

Under the fee agreement, the  (1)  can charge  (2)  no more than  (3)  for his or her work on  (4)  Social Security claim. The amount of the fee does not include any out-of-pocket expenses (for example, costs to get copies of doctors' or hospitals' reports). This is a matter between  (5)  and the  (6)  .


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: representative
Fill-in (2) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢ Amount
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (6) - Systems Generated
Choice 1: representative

ATY070 FEE AMOUNT – CONCURRENT TITLE II AND TITLE XVI CLAIMS – OFFSET INFORMATION PENDING – NH ONLY (L27)

(Requested)

Caption: Information About Representative's Fees

We base the amount of the  (1)  fee on the total past-due benefits for  (2)  and  (3)  family. Under the fee agreement, the  (4)  can charge  (5)   (6)  for his or her work. As soon as we make a decision on  (7)  family's claims and decide the amount of their past-due benefits, we will tell them if the  (8)  can charge an additional fee. We also will say how much that fee amount will be.

The amount of the fee for  (9)  and  (10)  family's claims does not include any out-of-pocket expenses (for example, costs to get copies of doctors' or hospitals' reports). This is a matter between  (11)  and the  (12)  .


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: representative's
Fill-in (2) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (3) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (4) - Systems Generated
Choice 1: representative
Fill-in (5) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (6) - Requested As A Money Amount In Format $$$$$.¢¢
Amount of the fee
Fill-in (7) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (8) - Systems Generated
Choice 1: representative
Fill-in (9) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (10) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (11) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (12) - Systems Generated
Choice 1: representative

ATY071 DETERMINATION OF REPRESENTATIVE'S ASSESSMENT AMOUNT – NH, NH AND AUXILIARIES OR AUXILIARIES ONLY – SSA PREVIOUSLY ASSESSED MAXIMUM (L37)

(Requested)

Caption: Information About Representative's Fees

We are paying the  (1)  from the benefits we withheld. We usually collect a service charge of 6.3 percent of the fee amount we pay, but not more than $98, which is the most we can collect in each case under the law. Because we paid a fee and collected the full amount before, there is no additional charge.  (2) 


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: (A) representative
Fill-in (2) - Requested As A One Position Alpha Character
Choice 1: (A) After we subtract the amount we are paying towards the fee, we will send you the balance of the amount we withheld.
Choice 1: (B) NULL

ATY800 FEE AGREEMENT APPROVED NUMBER HOLDER (L01)

(Requested)

Caption: Information About Representative's Fees

We have approved the fee agreement between you and your  (1)  .


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: representative

ATY801 FEE AGREEMENT APPROVED AUXILIARY (L02)

(Requested)

Caption: Information About Representative's Fees

When  (1)  filed  (2)  claim for benefits,  (3)  used a  (4)  to help with the claim. We have approved a fee agreement between  (5)  and  (6)   (7)  . The  (8)  work involved the benefits of everyone on the record.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary's Name
Fill-in (2) - Systems Generated
Choice 1: his
Choice 2: her
Fill-in (3) - Systems Generated
Choice 1: he
Choice 2: she
Fill-in (4) - Systems Generated
Choice 1: representative
Fill-in (5) - Systems Generated
Choice 1: Beneficiary's Name
Fill-in (6) - Systems Generated
Choice 1: the
Fill-in (7): - Systems Generated
Choice 1: representative
Fill-in (8) - Systems Generated
Choice 1: representative's

ATY804 FEE AGREEMENT AMOUNT NUMBER HOLDER TITLE II CLAIM ONLY (L03)

(Requested)

Caption: Information About Representative's Fees

 (1)  past-due benefits are  (2)  for  (3)  . Under the fee agreement, the  (4)  cannot charge you more than  (5)  for his or her work. The amount of the fee does not include any out-of-pocket expenses (for example, costs to get copies of doctors' or hospitals' reports). This is a matter between you and the  (6)  .


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary's Name possessive
Choice 2: Your
Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: past due benefits
Fill-in (3) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY and MM/CCYY
Choice 3: MM/CCYY through MM/CCYY
Fill-in (4) - Systems Generated
Choice 1: representative
Fill-in (5) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: pending fee amount
Fill-in (6) - Systems Generated
Choice 1: representative

ATY808 FEE REVIEW PROCEDURE NUMBER HOLDER (L06)

(Requested)

Caption: How To Ask Us To Review The Fee

You, the  (1)  or the person who decided your case can ask us to review the amount of the fee we say the  (2)  can charge.  (3) 

If you think the amount of the fee is too high, write us within 15 days from the day you get this letter. Tell us that you disagree with the amount of the fee and give your reasons. Send your request to this address:

Social Security Administration

Office of Disability Adjudication and Review

Attorney Fee Branch

5107 Leesburg Pike

Falls Church, Virginia 22041-3255

The  (4)  also has 15 days to write us if he or she thinks the amount of the fee is too low.  (5) 

If we do not hear from you or the  (6)  we will assume you both agree with the amount of the fee shown.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: representative
Fill-in (2) - Systems Generated
Choice 1: representative
Fill-in (3) - Requested As A One Position Alpha Character
Choice 1: (A) Your family members who have filed claims on your Social Security number (SSN) also may ask us to review the amount of the fee.
Choice 2: (B) null
Fill-in (4) - Systems Generated
Choice 1: representative
Fill-in (5) - Systems Generated
Choice 1: null
Choice 2: null
Fill-in (6) - Systems Generated
Choice 1: representative

ATY809 FEE REVIEW PROCEDURE AUXILIARY USED ONLY WHEN AUXILIARY PAID AT DIFFERENT TIMETHAN N/H OR LIVING IN SEPARATE HOUSEHOLD (L07)

(Requested)

Caption: How To Ask Us To Review The Fee

You,  (1)  , the  (2)  or the person who decided your case can ask us to review the amount of the fee we say the  (3)  can charge.

If you think the amount of the fee is too high, write us within 15 days from the day you get this letter. Tell us that you disagree with the amount of the fee and give your reasons. Send your request to this address:

Social Security Administration

Office of Disability Adjudication and Review

Attorney Fee Branch

5107 Leesburg Pike

Falls Church, Virginia 22041-3255

The  (4)  also has 15 days to write us if he or she thinks the amount of the fee is too low.  (5) 

If we do not hear from you or the  (6)  , we will assume you both agree with the amount of the fee shown.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary's Name
Fill-in (2) - Systems Generated
Choice 1: representative
Fill-in (3) - Systems Generated
Choice 1: representative
Fill-in (4) - Systems Generated
Choice 1: representative
Fill-in (5) - Systems Generated
Choice 1: null
Fill-in (6) - Systems Generated
Choice 1: representative

ATY816 NH FEE AGREEMENT DISAPPROVED NH REPRESENTED BY A REPRESENTATIVE. CAN ALSO BE USED WITH L14 OR L21 IN SSI/FEE PETITION CASE (L20)

(Requested)

Caption: Information About Representative's Fees

If your  (1)  wants us to pay the fee from your withheld benefits, he or she must ask us to approve the fee within 60 days of the date of this letter.

If your  (2)  :

  • Is finished working on this case and wants to charge a fee, he or she must tell us to approve the amount of the fee right away.

  • Is not finished working on this case and wants to charge a fee, he or she must tell us within 60 days of the date of this letter that he or she will ask for a fee.

  • Does not want to charge a fee or does not want us to pay the fee from the benefits we withheld, he or she should tell us right away.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: representative
Fill-in (2) - Systems Generated:
Choice 1: representative

ATY817 REVIEW OF THE DISAPPROVED FEE AGREEMENT – NH (L18)

(Requested)

Caption: How To Ask Us To Review The Determination On The Fee Agreement

You or the  (1)  can ask us to review the determination on the fee agreement. If you decide to ask us for a review, write us within 15 days from the day you get this letter. Tell us that you disagree and give your reasons. Send your request to this address:

Social Security Administration

Office of Disability Adjudication and Review

Attorney Fee Branch

5107 Leesburg Pike

Falls Church, Virginia 22041-3255

The  (2)  also has 15 days to write us if he or she does not agree with the determination on the fee agreement.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: representative
Fill-in (2) - Systems Generated
Choice 1: representative

ATY825 FEE AGREEMENT AMOUNT CONCURRENT TITLE II/TITLE XVI ADDITIONAL FEE FOR TITLE XVI CLAIM NUMBER HOLDER ONLY USE IN INITIALAWARDS/POSTENTITLEMENT/CESSATION CASES (L31)

(Requested)

Caption: Information About Representative's Fees

If we approve your claim for SSI, the  (1)  may be able to charge an additional amount for his or her work. We will send you another letter about SSI telling you the additional amount of the fee, if any, he or she can charge.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: representative

ATY834 FEE AGREEMENT AMOUNT NH AND AUXILIARIES TITLE II CLAIM ONLY (L04)

(Requested)

Caption: Information About Representative's Fees

 (1)  past-due benefits are  (2)  for  (3)  .  (4)  family's past-due benefits are  (5)  for  (6)  . Under the fee agreement, the  (7)  cannot charge  (8)  and  (9)  family more than  (10)  for his or her work. The amount of the fee does not include any out-of-pocket expenses (for example, costs to get copies of doctors' or hospitals' reports). This is a matter between you and the  (11)  .


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Full name possessive
Choice 2: Your
Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: money amount
Fill-in (3) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (4) - Systems Generated
Choice 1: Your
Choice 2: Her
Choice 3: His
Fill-in (5) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: money amount
Fill-in (6) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (7) - Systems Generated
Choice 1: representative
Fill-in (8) - Systems Generated
Choice 1: Beneficiary's Name
Choice 2: you
Fill-in (9) - Systems Generated
Choice 1: your
Choice 2: her
Choice 3: his
Fill-in (10) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: pending fee amount
Fill-in (11) - Systems Generated
Choice 1: representative

ATY836 REPRESENTATIVE INVOLVED – SSA WITHHOLDING PAST DUE BENEFITS – NH (L09)

(Requested)

Caption: Information About Past-Due Benefits Withheld To Pay A Lawyer

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) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Amount
Fill-in (2) - Systems Generated
Choice 1: Mr. Beneficiary's Name possessive
Choice 2: Ms. Beneficiary's Name possessive
Choice 3: Beneficiary's First Name possessive
Choice 4: Beneficiary's Name possessive
Choice 5: your
Fill-in (3) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
Choice 4: Beneficiary's Name possessive
Choice 5: the

ATY838 REPRESENTATIVE FEE AGREEMENT – TITLE II/TITLE XVI SSA WITHHOLDING PAST DUE BENEFITS – N/H AND AUXILIARIES (L21)

(Requested)

Caption: Information About Past-Due Benefits Withheld To Pay A Lawyer

Because of the law, we usually withhold 25 percent of the total past-due benefits to pay an approved  (1)  fee.

We withheld  (2)  from  (3)  past-due benefits to pay  (4)   (5)  . We also withheld  (6)  from  (7)  family's past-due benefits. We base the amount of the fee  (8)   (9)  can charge on the total past-due benefits due  (10)  and  (11)  family.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: representative's
Fill-in (2) - Systems Generated
Representative Fee Amount
Fill-in (3) - Systems Generated
Choice 1: Beneficiary's Name possessive
Choice 2: your
Fill-in (4) - Systems Generated
Choice 1: the
Fill-in (5) - Systems Generated
Choice 1: representative
Fill-in (6) - Systems Generated
Choice 1: Amount
Fill-in (7) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
Fill-in (8) - Systems Generated
Choice 1: the
Fill-in (9) - Systems Generated
Choice 1: representative
Fill-in (10) - Systems Generated
Choice 1: Beneficiary Name
Choice 2: you
Fill-in (11) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your

ATYR02 FEE AMOUNT UNKNOWN-NH PAST-DUE BENEFITS UNKNOWN OR AUXILIARY (IES) CLAIM PENDING (L08)

(Requested)

Caption: Information About Representative's Fees

We base the amount of  (1)  fee on past-due benefits, if any. As soon as we  (2)  determine the amount of past-due benefits, we will tell you the amount of the fee  (3)  can charge.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your representative's
Choice 2: the representative's
Fill-in (2) - Requested As A One Position Alpha Character
Choice 1: (A) make a decision on your spouse's claim and
Choice 2: (B) make a decision on your family's claims and
Choice 3: (C) make a decision on your child's claim and
Choice 4: (D) make a decision on your children's claim and
Choice 5: (E) Null
Fill-in (3) - Systems Generated
Choice 1: your representative
Choice 2: the representative

ATYR03 FEE AGREEMENT SUBSEQUENTLY DISAPPROVED – NO PAST DUE BENEFITS – NH – TITLE II ONLY (L29)

(Requested)

Caption Information About Representative's Fees

We wrote you before and said we had approved the fee agreement between  (1)  and the  (2)  . We also said we would tell  (3)  and the  (4)  the amount of the fee he or she can charge  (5)  .

We base the fee amount we allow under a fee agreement on  (6)  past-due benefits. There are no past-due benefits. Therefore, we no longer approve the fee agreement between  (7)  and the  (8)  .

Even though we no longer approve the fee agreement, the  (9)  can still charge a fee for his or her services. If the  (10)  wants to charge a fee, he or she must ask us in writing to approve the fee. The  (11)  must give  (12)  a copy of his or her fee request and each attachment to the request. If the  (13)  does not want to charge a fee, he or she should tell us.


Fill-in values:
Fill-in (1) - Requested As A Language
Choice 1: Name of Beneficiary who hired the attorney or representative
Fill-in (2) - Systems Generated
Choice 1: representative
Fill-in (3 - Systems Generated
Choice 1: Ms. + Beneficiary's Last Name
Choice 2: Mr. + Beneficiary's Last Name
Choice 3: Beneficiary's First Name
Choice 4: Beneficiary's Name
Choice 5: you
Fill-in (4 - Systems Generated
Choice 1: representative
Fill-in (5 - Systems Generated
Choice 1: Ms. + Beneficiary's Last Name
Choice 2: Mr. + Beneficiary's Last Name
Choice 3: Beneficiary's First Name
Choice 4: Beneficiary's Name
Choice 5: you
Fill-in (6) - Systems Generated
Choice 1: her
Choice 2: his
Choice 3: your
Fill-in (7) - Systems Generated
Choice 1: her
Choice 2: him
Choice 3: you
Fill-in (8) - Systems Generated
Choice 1: representative
Fill-in (9) - Systems Generated
Choice 1: representative
Fill-in (10) - Systems Generated
Choice 1: representative
Fill-in (11) - Systems Generated
Choice 1: representative
Fill-in (12) - Systems Generated
Choice 1: her
Choice 2: him
Choice 3: you
Fill-in (13) - Systems Generated
Choice 1: representative

ATYR05 FEE AGREEMENT AMOUNT AUXILIARY TITLE II CLAIM ONLY -USED ONLY WHEN AUXILIARY PAID AT DIFFERENT TIME THAN N/H OR LIVING IN SEPARATE HOUSEHOLD (L16)

(Requested)

Caption: Information About Representative's Fees

 (1)  past-due benefits are  (2)  for  (3)  . Under the fee agreement between  (4)  and the  (5)  , the  (6)  cannot charge more than  (7)  for his or her work.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Full name possessive
Fill-in (2) - Systems Generated
Choice 1: amount
Fill-in (3) - Systems Generated
Choice 1: month and year
Choice 2: month and year through month and year
Fill-in (4) - Requested As A Language
Choice 1: Beneficiary's Name
Fill-in (5) - Systems Generated
Choice 1: representative
Fill-in (6) - Systems Generated
Choice 1: representative
Fill-in (7) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: money amount

ATYR12 REPRESENTATIVE INVOLVED – SSA WITHHOLDING PAST-DUE BENEFITS – AUXILIARY (IES) (L11)

(Requested)

Caption: Information About Past-Due Benefits Withheld To Pay A Representative

Because of the law, we usually withhold 25 percent of the total past-due benefits to pay an approved  (1)  fee. We withheld  (2)  from  (3)  past-due benefits to pay  (4)   (5)  .


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: representative's
Fill-in (2) - Systems Generated
Choice 1: (Amount)
Fill-in (3) - Systems Generated
Choice 1: Beneficiary's Name possessive
Choice 2: your
Fill-in (4) - Systems Generated
Choice 1: the
Fill-in (5) - Systems Generated
Choice 1: representative

ATYR15 FEE AGREEMENT NOT APPROVED – NH (L19)

(Requested)

Caption: Information About Representative's Fees

We cannot approve the fee agreement between you and your representative because  (1) 

Even though we cannot approve the fee agreement, your representative can still charge you a fee for his or her services. If your representative wants to charge a fee, he or she must ask us in writing to approve the amount of the fee. Your representative must give you a copy of his or her fee request and each attachment to the request. If your representative does not want to charge a fee, he or she should tell us.


Fill-in values:
Fill-in (1) - Requested As A One Position Alpha Character
Choice 1: (A) we did not get a written agreement before we decided your claim.
Choice 2: (B) both you and your representative did not sign the agreement.
Choice 3: (C) it sets a fee amount that is more than the lesser of 25 percent of past-due benefits or $6000.00.
Choice 4: (D) there are no past-due benefits. We base the fee amount we allow under a fee agreement on your past-due benefits. Since we do not owe you any past-due benefits, we cannot approve the fee agreement.
Choice 5: (E) you appointed more than one representative, and not all representatives signed onto a single fee agreement.
Choice 6: (F) you discharged a representative, or a representative withdrew from the case, before we favorably decided the claim (unless the former representative waived any fee in your case).
Choice 7: (G) your representative died before we issued the favorable decision.
Choice 8: (H) you were declared legally incompetent by a State court and your guardian did not sign the fee agreement.

ATYR20 FEE AMOUNT – TITLE II CLAIM ONLY – NH ONLY – DELAYED AUXILIARY CLAIM(S) PENDING OR EXPECTED – NH'S AWARD NOTICE (L25)

(Requested)

Caption: Information About Representative's Fees

We base the amount of the  (1)  fee on the total past-due benefits for you and your family. Your past-due benefits are  (2)  for  (3)  . Under the fee agreement, the  (4)  can charge you  (5)  for his or her work. As soon as we make a decision on your family's claim(s) and decide the amount of their past-due benefits, we will tell them if the  (6)  can charge an additional fee. We also will say how much that fee amount will be.

The amount of the fee for your and your family's claim(s) does not include any out-of-pocket expenses (for example, costs to get copies of doctors' or hospitals' reports). This is a matter between you and the  (7)  .


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: representative's
Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: PDB
Choice 2: PMA
Fill-in (3) - Systems Generated
Choice 1: DOEC in the format Month CCYY
Choice 2: DOES through LAST-WITHHOLDING-DATE in the format Month CCYY and Month CCYY
Choice 3: the period from DOEC through LAST-WITHHOLDING- DATE in the format Month CCYY through Month CCYY
Fill-in (4) - Systems Generated
Choice 1: representative
Fill-in (5) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Pending-Fee-Agreement-Amount
Fill-in (6) - Systems Generated
Choice 1: representative
Fill-in (7) - Systems Generated
Choice 1: representative

ATYR22 FEE AMOUNT – CONCURRENT TITLE II AND TITLE XVI CLAIMS – OFFSET INFORMATION PENDING – NH AND NON-DELAYED AUXILIARY BENEFICIARY(IES) – DELAYED AUXILIARY CLAIMS PENDING OR EXPECTED – NH'S AWARD NOTICE(L26)

(Requested)

Caption: Information About Representative's Fees

We base the amount of the  (1)  fee on the total past-due benefits for you and your family. Your past-due benefits are  (2)  for  (3)  .  (4)  past-due benefits are  (5)  for  (6)  . Under the fee agreement, the  (7)  can charge you and  (8)   (9)  for his or her work. As soon as we make a decision on your  (10)  and decide the amount of the past-due benefits, we will tell  (11)  if the  (12)  can charge an additional fee. We also will say how much that fee amount will be.

The amount of the fee for your and your family's claim(s) does not include any out-of-pocket expenses (for example, costs to get copies of doctors' or hospitals' reports). This is a matter between you and the  (13)  .


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: representative's
Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: sum of number holder's PMA and LPDA
Choice 2: number holder's PMA
Fill-in (3) - Requested As A Date In Format Shown Below
Choice 1: DOEC in the format MONTH CCYY
Choice 2: DOEC through LAST-WITHHOLDING-DATE in the format MONTH CCYY and MONTH CCYY
Choice 3: the period from DOEC through LAST_WITHHOLDING- DATE in the format MONTH CCYY through MONTH CCYY
Fill-in (4) - Requested As A One Position Alpha Character
Choice 1: (A) Beneficiary's Name, possessive
Choice 2: (B) Your family's
Fill-in (5) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Money Amount
Fill-in (6) - Systems Generated
Choice 1: DOEC in the format MONTH CCYY
Choice 2: DOEC through LAST-WITHHOLDING-DATE in the format MONTH CCYY and MONTH CCYY
Choice 3: the period from DOEC through LAST-WITHHOLDING- DATE in the format MONTH CCYY through MONTH CCYY
Fill-in (7) - Systems Generated
Choice 1: representative
Fill-in (8) - Systems Generated
Choice 1: Beneficiary's Name, possessive
Choice 2: your family
Fill-in (9) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Money Amount
Fill-in (10) - Requested As A One Position Alpha Character
Choice 1: (A) spouse's claim
Choice 2: (B) other child's claim
Choice 3: (C) other children's claims
Choice 4: (D) spouse's and other child's claims
Choice 5: (E) spouse's and other children's claims
Fill-in (11) - Systems Generated
Choice 1: him
Choice 2: her
Choice 3: them
Fill-in (12) - Systems Generated
Choice 1: representative
Fill-in (13) - Systems Generated
Choice 1: representative

NL 00720.095 CLO Closeout

CLO002 GENERAL CLOSEOUT FOR AWARDS (G19)

(System Generated)

Caption: Other Social Security Benefits

 (1)   (2)  can receive from us at this time. In the future, if you think  (3)  might qualify for another benefit from us,  (4)  will need to apply again.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: This benefit is the only benefit
Choice 2: These benefits are the only benefits
Fill-in (2) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (3) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (4) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she

CLO029 AD, B TO D, AND AB TO AD CONVERSION HIGHER BENEFITS POSSIBLE ON PRIOR SPOUSE'S RECORD (B35)

(Requested)

Caption: Other Social Security Benefits

If  (1)  married more than once, please contact us.  (2)  may be able to get a higher benefit on the record of a prior spouse.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you were
Choice 2: he was
Choice 3: she was
Fill-in (2) - Systems Generated
Choice 1: You
Choice 2: He
Choice 3: She

CLOR05 CLOSE OUT ANOTHER CLAIM PENDING (B56)

(Requested)

Caption: Other Social Security Benefits

This  (1)  benefit is the only benefit we can pay  (2)  at this time. We will let you know if  (3)  eligible for  (4)  benefits.  (5)  cannot receive any other type of benefits based on the application  (6)  filed.


Fill-in values:
Fill-in (1) - Requested As A One Position Alpha Character
Choice 1: (A) retirement
Choice 2: (B) wife's
Choice 3: (C) husband's
Choice 4: (D) widow's
Choice 5: (E) widower's
Choice 6: (F) mother's
Choice 7: (G) father's
Choice 8: (H) parent's
Choice 9: (I) disabled widow's
Choice 10: (J) disabled widower's
Choice 11: (K) disabled divorced widow's
Choice 12: (L) disabled divorced widower's
Choice 13: (M) child's
Choice 14: (N) lump sum death payment
Fill-in (2) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (3) - Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (4) - Requested As A One Position Alpha Character
Choice 1: (A) retirement
Choice 2: (B) wife's
Choice 3: (C) husband's
Choice 4: (D) widow's
Choice 5: (E) widower's
Choice 6: (F) mother's
Choice 7: (G) father's
Choice 8: (H) parent's
Choice 9: (I)disabled widow's
Choice 10: (J) disabled widower's
Choice 11: (K) disabled divorced widow's
Choice 12: (L) disabled divorced widower's
Choice 13: (M) child's
Choice 14: (N) lump sum death payment
Fill-in (5) - Systems Generated
Choice 1: You
Choice 2: He
Choice 3: She
Fill-in (6) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she

CLOR11 AWARD CLOSEOUT OTHER POTENTIAL CLAIM GIVEN 6-MONTH CLOSEOUT (B11)

(Requested)

Caption: Other Social Security Benefits

The  (1)  benefit is the only kind of benefit  (2)   (3)  entitled to receive, with the possible exception of  (4)  benefits. You told us when you applied for  (5)  benefits  (6)   (7)  that you did not wish to apply for  (8)  benefits  (9)  at that time.

If you change your mind, you need to apply for these benefits. The application date can make a difference in the amount we pay. If you apply within 6 months of the date of this letter, we may be able to use the date of your application for  (10)  benefits as the date of your application for  (11)  benefits.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: retirement
Choice 2: disability
Fill-in (2) - Systems Generated
Choice 1: you
Choice 2: Beneficiary name
Fill-in (3) - Systems Generated
Choice 1: are
Choice 2: is
Fill-in (4) - Requested As A One Position Alpha Character
Choice 1: (A) retirement
Choice 2: (B) disability
Choice 3: (C) spouse’s
Choice 4: (D) widow’s
Choice 5: (E) widower’s
Choice 6: (F) mother’s
Choice 7: (G) father’s
Choice 8: (H) child’s
Choice 9: (I) parent’s
Choice 10: (J) disabled widow’s
Choice 11: (K) disabled widower’s
Choice 12: (L) disabled divorced widow’s
Choice 13: (M) disabled divorced widower’s
Fill-in (5) - Systems Generated
Choice 1: retirement
Choice 2: disability
Fill-in (6) - Systems Generated
Choice 1: for
Choice 2: null
Fill-in (7) - Systems Generated
Choice 1: Beneficiary name
Choice 2: null
Fill-in (8) - Requested As A One Position Alpha Character
Choice 1: (A) retirement
Choice 2: (B) disability
Choice 3: (C) spouse’s
Choice 4: (D) widow’s
Choice 5: (E) widower’s
Choice 6: (F) mother’s
Choice 7: (G) father’s
Choice 8: (H) child’s
Choice 9: (I) parent’s
Choice 10: (J) disabled widow’s
Choice 11: (K) disabled widower’s
Choice 12: (L) disabled divorced widow’s
Choice 13: (M) disabled divorced widower’s
Fill-in (9) - Systems Generated
Choice 1: for him
Choice 2: for her
Choice 3: null
Fill-in (10) - Systems Generated
Choice 1: retirement
Choice 2: disability
Fill-in (11) - Requested As A One Position Alpha Character
Choice 1: (A) retirement
Choice 2: (B) disability
Choice 3: (C) spouse’s
Choice 4: (D) widow’s
Choice 5: (E) widower’s
Choice 6: (F) mother’s
Choice 7: (G) father’s
Choice 8: (H) child’s
Choice 9: (I) parent’s
Choice 10: (J) disabled widow’s
Choice 11: (K) disabled widower’s
Choice 12: (L) disabled divorced widow’s
Choice 13: (M) disabled divorced widower’s

CLOR12 AWARD CLOSEOUT POTENTIAL AUXILIARY AND FAMILY CLAIM GIVEN 6-MONTH CLOSEOUT (B12)

(Requested)

Caption: Other Social Security Benefits

The  (1)  benefit is the only kind of benefit  (2)   (3)  family are entitled to receive, with the possible exception of  (4)  benefits. You told us when you applied for  (5)  benefits  (6)   (7)  that  (8)  did not wish to apply for  (9)  benefits at that time.

If  (10)  mind,  (11)  to apply for these benefits. The application date can make a difference in the amount we pay. If  (12)  within 6 months of the date of this letter, we may be able to use the date of the application for  (13)  benefits  (14)   (15)  as the date of application for  (16)  benefits.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: retirement
Choice 2: disability
Fill-in (2) - Systems Generated
Choice 1: you and your family
Choice 2: Number Holder's Fullname
Fill-in (3) - Systems Generated
Choice 1: and his
Choice 2: and her
Choice 3: null
Fill-in (4) - Requested As A One Position Alpha Character
Choice 1: (A) wife's
Choice 2: (B) husband's
Choice 3: (C) child's
Fill-in (5) - Systems Generated
Choice 1: retirement
Choice 2: disability
Fill-in (6) - Systems Generated
Choice 1: for
Choice 2: null
Fill-in (7) - Systems Generated
Choice 1: Number Holder's fullname
Choice 2: null
Fill-in (8) - Requested As A One Position Alpha Character
Choice 1: (A) you
Choice 2: (B) your wife
Choice 3: (C) your husband
Choice 4: (D) your child
Fill-in (9) - Requested As A One Position Alpha Character
Choice 1: (A) wife's
Choice 2: (B) husband's
Choice 3: (C) child's
Fill-in (10) - Requested As A One Position Alpha Character
Choice 1: (A) you change your
Choice 2: (B) your wife changes her
Choice 3: (C) your husband changes his
Choice 4: (D) your child changes his
Choice 5: (E) your child changes her
Fill-in (11) - Systems Generated
Choice 1: you need
Choice 2: he needs
Choice 3: she needs
Fill-in (12) - Requested As A One Position Alpha Character
Choice 1: (A) you apply
Choice 2: (B) your wife applies
Choice 3: (C) your husband applies
Fill-in (13) - Systems Generated
Choice 1: retirement
Choice 2: disability
Fill-in (14) - Systems Generated
Choice 1: for
Choice 2: null
Fill-in (15) - Systems Generated
Choice 1: Number Holder's Surname
Fill-in (16) - Requested As A One Position Alpha Character
Choice 1: (A) wife's
Choice 2: (B) husband's
Choice 3: (C) child's

CLOR13 LUMP-SUM DEATH PAYMENT AWARD CLOSEOUT OTHER POTENTIAL CLAIM GIVEN 6-MONTH CLOSEOUT (B13)

(Requested)

Caption: Other Social Security Benefits

The lump-sum death payment is the only kind of payment  (1)   (2)  entitled to receive, with the possible exception of  (3)  benefits. You told us when you applied for the lump-sum death payment  (4)   (5)  that you did not wish to apply for  (6)  benefits  (7)  at that time.

If you change your mind, you need to apply for these benefits. The application date can make a difference in the amount we pay. If you apply within 6 months of the date of this letter, we may be able to use the date of the application for  (8)  benefits.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you
Choice 2: Fullname
Fill-in (2) - Systems Generated
Choice 1: are
Choice 2: is
Fill-in (3) - Systems Generated
Choice 1: retirement
Choice 2: disability
Fill-in (4) - Systems Generated
Choice 1: for
Choice 2: null
Fill-in (5) - Systems Generated
Choice 1: Surname
Choice 2: null
Fill-in (6) - Systems Generated
Choice 1: wife's
Choice 2: husband's
Choice 3: child's
Fill-in (7) - Systems Generated
Choice 1: for him
Choice 2: for her
Choice 3: null
Fill-in (8) - Systems Generated
Choice 1: wife's
Choice 2: husband's
Choice 3: child's

CLOR20 AUXILIARY CLAIMANT NOT INSURED ON OWN RECORD (Q04)

(Requested)

Caption: Your Benefits

Benefits are not payable on your own record because you have not worked long enough under Social Security. To qualify, you need credit for  (1)  calendar quarters of work. You now have  (2)  . If you earn the additional quarters, please contact any Social Security office.


Fill-in values:
Fill-in (1) - Requested As A Number
Choice 1: required QCs
Fill-in (2) - Requested As A Number
Choice 1: acquired QCs

NL 00720.280 REF Referral

REF001 FIELD OFFICE REFERRAL DOMESTIC (G20)

(System Generated)

Caption: If You Have Any Questions

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

 (2) 

 (3) 

 (4) 

 (5) 

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


Fill-in values:
No Fill-in needed
Office address line 1
Office address line 1
Office address line 2
Office address line 3

REF003 DOMESTIC REFERRAL PARAGRAPH (G28)

(System Generated)

Caption: If You Have Any Questions

We invite you to visit our website at www.socialsecurity.gov on the Internet to find general information about Social Security.

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

 (2) 

 (3) 

 (4) 

 (5) 

If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.


Fill-in values:
FO Phone Number
Fill-ins
Choice 1: FO street address
Choice 2: city, state and zip code
FO Address
FO Address
FO Address

REF008 REFERRAL DOMESTIC DEFAULT (G21)

(System Generated)

Caption: If You Have Any Questions

We invite you to visit our website at www.socialsecurity.gov on the Internet to find general information about Social Security.

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


Fill-in value:
no Fill-in needed

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

(System Generated)

Caption: If You Have Any Questions

We invite you to visit our website at  (1)  on the Internet to find general information about Social Security. However, if you have any specific  (2)  questions, you can call us at 1-800-772-1213. We can answer most questions over the phone. If you are deaf or hard of hearing, you may call our TTY number, 1-800-325-0778. You can also write or visit any Social Security office. The office that serves your area is located at:

 (3) 

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

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


Fill-in values:
Fill-in
www.socialsecurity.gov
Fill-in
Null
Fill-in
Street Address, City, State and Zip Code from DOORS

REF137 (GA7) BOND UTI

(System Generated)

Caption: If You Have Questions About The BOND Project

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


Fill-in value:

REF140 RRB FOREIGN REFERRAL PARAGRAPH (G38)

(System Generated)

Caption: If You Have Any Questions

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

If you have any questions about railroad annuities or about your monthly check, please contact your local Railroad District Office or the Railroad Retirement Board. The address is U.S. Railroad Retirement Board, 844 Rush Street, Chicago, IL. 60611-2092, U.S.A.


Fill-in values:
Fill-in (1) Systems Generated
Fill-in (2) Systems Generated
Choice 1: your
Choice 2: Beneficiary's name possessive

REF141 REFERRAL DEFAULT (G39)

(System Generated)

Caption: If You Have Questions

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

If you have any questions about railroad annuities or about your monthly check, please contact your local Railroad District Office or the Railroad Retirement Board. The address is U.S. Railroad Retirement Board, 844 Rush Street, Chicago, Illinois 60611-2092.


Fill-in value: None

REF142 RRB DOMESTIC REFERRAL PARAGRAPH (G29)

(System Generated)

Caption: If You Have Questions

We invite you to visit our website atwww.socialsecurity.gov  (1)  on the Internet to find general information about Social Security. If you have any specific questions, you may call us toll free at 1-800-772-1213, or call your local Social Security office at  (2)  . We can answer most questions over the phone. If you are deaf or hard of hearing, you may call our TTY number, 1-800-325-0778. You can also write or visit any Social Security office. The office that serves your area is located at:

 (3) 

 (4) 

 (5) 

 (6) 

If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

If you have any questions about railroad annuities or about your monthly check, please contact your local Railroad District Office or the Railroad Retirement Board. The address is U.S. Railroad Retirement Board, 844 Rush Street, Chicago, IL. 60611-2092.


Fill-in values:
Office phone number in format 1-999-999-9999
Office address line 1
Office address line 2
Office address line 3
Office address line 4

REF185 REFERRAL FOREIGN (G22)

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 17769,
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) Systems Generated
Choice 1: www.ssa.gov
Fill-in (2) Systems Generated
Fill-in (3) Systems Generated
Fill-in (4) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) Systems Generated
Choice 1: Medicare.gov

NL 00720.295 RFU Refund

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

(Requested/Generated)

Caption: How To Pay Us Back

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

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

  • A partial payment

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

  • A plan to repay the money


Fill-in values:
Fill-in (1) – Systems Generated (when it is not requested on the ENB) or Requested As A Money Amount in Format $$$$$.¢¢
Overpayment Amount
Fill-in (2) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3) Systems Generated (when it is not requested on the ENB) Requested As A Money Amount in Format $$$$$.¢¢
Overpayment Amount

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

(Requested)

Caption: How To Pay Us Back

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

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

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

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

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


Fill-in values:
Fill-in (1) Systems Generated
Amount of Overpayment
Fill-in (2) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (4) Systems Generated
Choice 1: NULL
Choice 2: for him
Choice 3: for her
Fill-in (5) Systems Generated
MM/DD/CCYY
Fill-in (6) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (7) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (8) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

RFU007 SSI OFFSET NOT APPLICABLE (A59)

(Requested)

Caption: Your Benefits

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


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (2) Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY

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

(Requested)

Caption: Your Benefits

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


Fill-in values:
Fill-in (1) Requested As A One Position Alpha Character
Choice 1: (A) some of
Choice 2: (B) null
Fill-in (2) Requested As A One Position Alpha Character
Choice 1: (A) incorrectly paid
Choice 2: (B) overpaid
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Choice 4: Beneficiary's Name

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

(Requested/Generated)

Caption: How To Pay Us Back

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

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

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

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

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


Fill-in values:
Fill-in (1) - Systems Generated (when it is not requested on the ENB) Requested As A Money Amount in Format $$$$$.¢¢
Overpayment Amount
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (4) - Systems Generated
Choice 1: null
Choice 2: for him
Choice 3: for her
Fill-in (5) - Systems Generated (when it is not requested on the ENB) Requested As A Date In Format Shown Below
MM/DD/CCYY
Fill-in (6) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (7) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (8) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

RFU020 FOREIGN REFUND REQUEST NONPAY STATUS (F19)

Caption: How To Pay Us Back

(System Generated)

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

  1. a. 

    partial payment,

  2. b. 

    an explanation of your financial circumstances, and

  3. c. 

    a definite plan for repaying the balance.

If  (3)  pay us by check or money order, make sure that the check or money order is in United States (U.S.) dollars or in local currency equal to U.S. dollars. When (4)  pay us in local currency, we use the exchange rates in effect at the time we get  (5)  payment. If this causes a difference between the amount  (6)  pay us and the amount  (7)  us, we will let you know. If you cannot mail  (8)  payment to us, please contact your Federal Benefits Unit. Visit  (9)  for a list of FBUs. If you are in Canada, visit  (10)  to find the office that services your area. They will help you make the refund.

If you have questions about Medicare, please visit  (11)  for information.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: Beneficiary's name possessive
Choice 2: your
Fill-in (2) Systems Generated
Overpayment amount in $$$$$¢¢
Fill-in (3) Systems Generated
Choice 1: you pay
Choice 2: he pays
Choice 3: she pays
Fill-in (4) Systems Generated
Choice 1: you pay
Choice 2: he pays
Choice 3: she pays
Fill-in (5) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (6) Systems Generated
Choice 1: you pay
Choice 2: he pays
Choice 3: she pays
Fill-in (7) Systems Generated
Choice 1: you owe
Choice 2: he owes
Choice 3: she owes
Fill-in (8) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (9) Systems Generated
Fill-in (10) Systems Generated
www.ssa.gov/foreign/canada.htm
Fill-in (11) Systems Generated
Medicare.gov

NL 00720 TN 16 - Manual Adjustment, Credit and Award Process (MADCAP) Beneficiary Notice Print Program - 12/11/2020