Identification Number:
NL 00725 TN 23
Intended Audience:See Transmittal Sheet
Originating Office:OITEBS
Title:Modernized Claims Systems (MCS) Universal Text Identifiers (UTIs)
Type:POMS Transmittals
Program:Title II (RSI); Title XVI (SSI)
Link To Reference:
 
PROGRAM OPERATIONS MANUAL SYSTEM

Part 09 - Notices, Letters and Paragraphs

Chapter 007 - Letters and Paragraphs for Title II, Title XVI, and Title XVIII

Subchapter 25 - Modernized Claims System (MCS) Notices

Transmittal No. 23, 12/2017


Audience

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

Originating Component

OITEBS

Effective Date

Upon Receipt

Background

We are moving subsection NL 00725.005B, effective with the new release of the Modernized Claims System’s (MCS), by placing all the UTIs listed in this subsection in alphabetical order in separate new sections due to formatting issues. We are not changing policy or procedure.

Summary of Changes

NL 00725.005 Modernized Claims Systems (MCS) Universal Text Identifiers (UTIs)

Subsection B, we are removing this subsection and placing the information in new sections NL 00725.105 to NL 00725.490.

NL 00725.105 to NL 00725.230 are new sections.

NL 00725.105 “AAA” UTI

NL 00725.110 “AET” UTIs – Annual Earnings Test

NL 00725.115 “AGE” UTIs – Age

NL 00725.120 “ALS” UTIs – Appeals

NL 00725.125 “APS” UTIs – Applicant Statements

NL 00725.130 “ATY” UTIs – Attorney Fee

This is a new section. We are updating UTI ATY836 to remove mention of SSI from the title.

NL 00725.135 “BEN” UTIs - Benefit Information

NL 00725.140 “BRR” UTIs - Beneficiary Reporting Responsibilities

NL 00725.145 “CDR” UTIs – Continuing Disability Review

NL 00725.150 “CHK” UTIs

NL 00725.155 “CIC” UTIs – Child In Care

NL 00725.160 “CLO” UTIs – Closeout

NL 00725.165 “COA” UTIs

NL 00725.170 “COL” UTIs – Cost of Living

NL 00725.175 “COP” UTIs – Copy of Notice

NL 00725.180 “CTZ” UTIs – Citizenship

NL 00725.185 “DAA” UTIs – Drug Addiction and Alcoholism

NL 00725.190 “DDD” UTIs – Disability Date Denials

NL 00725.195 “DEP” UTIs – Dependents

NL 00725.200 “DIB” UTIs – Disability

NL 00725.205 “DID” UTIs

NL 00725.210 “DOB” UTIs

NL 00725.215 “DSL” UTIs – Disallowance

NL 00725.220 “ENC” UTIs – Enclosure

NL 00725.225 “ENT” UTIs – Entitlement

NL 00725.230 “ERN” UTIs – Earnings

<div class="poms">

NL 00725.005 Modernized Claims Systems (MCS) Universal Text Identifiers (UTIs)

List of all MCS UTI alpha designations

AET

Annual Earnings Test

AGE

Age

ALS

Appeals

APP

Applicant Statements

ATY

Attorney Fee

BEN

Benefit Information

BRR

Beneficiary Reporting Responsibilities

CDR

Continuing Disability Review

CIC

Child In Care

CLO

Closeout

COL

Cost of Living

COP

Copy of Notice

CTZ

Citizenship

DAA

Drug Addiction and Alcoholism

DDD

Disability Date Denials

DEP

Dependents

DIB

Disability

DSL

Disallowance

ENC

Enclosure

ENT

Entitlement

ERN

Earnings

FOB

Filing for Other Benefits

FRZ

Freeze

FUG

Fugitive Felon

FWK

Foreign Work

GAR

Garnishment

GPO

Government Pension Offset

HIB

Health Insurance Benefits

IDN

Identification

INF

Reminder/Informational

INS

Insured Status

ISC

Payment Summary

LSP

Lump Sum Payment

MAR

Marriage

MHP

Medicare Health Plan

MIS

Miscellaneous

MOE

Month of Entitlement

MPD

Income Related Monthly Reduction Amount

MSV

Military Service

ONS

Disability Onset Paragraphs

PAY

Payment

PMT

Payment Cycling

PRI

Prisoner Provisions

RDE

Rate Decrease

REC

Reconsideration Decision

REF

Referral

REL

Family Relationship

REP

Attorney Representation

RIN

Rate Increase

RPY

Representative Payee

RRB

Railroad Retirement Board

RSD

Residence

SEI

Self-Employment Income

SSA

Headings and Signatures

STU

Student Status

SUS

Suspensions deleted (for other than work)

TAX

Taxation of Benefits

TER

Terminations

TOT

Totalization

TWP

Trial Work Period

VRN

Vocational Rehabilitation

VTW

Voluntary Tax Withholding

WCP

Workers' Compensation

WDS

Work & Earnings facility of payment

WDW

Withdrawal

WEP

Windfall Elimination Provision

WFO

Windfall Offset

NL 00725.105 “AAA” UTI

AAAD01 Dictated Text

NL 00725.110 “AET” UTIs – Annual Earnings Test

AETC03 Caption

Work and Earnings Affect Payments

AETD03 Dictated Text

AET002 LMETY Year Established, Earnings Reported

The monthly earnings test applies only to 1 year. That year is the first year a beneficiary has a non-work month after entitlement to Social Security benefits. Our records show that  (1)  had or will have at least one non-work month in  (2)  . Therefore, we will pay  (3)  benefits for years after  (4)  based on the total amount  (5)   (6)  each year.

Fill-ins:

(1) FN

(2) LMETY year

(3) PN

(4) LMETY year

(5) PN

(6) “earn”/“earns”

AET003 LMETY Established, No Earnings Reported

The monthly earnings test applies only to 1 year. That year is the first year a beneficiary has a non-work month after entitlement to Social Security benefits. Our records show that  (1)  had or will have at least one non-work month in  (2)  . If  (3)  ever  (4)  to work, we will pay benefits for each year based on  (5)  work and earnings for that year.

Fill-ins:

(1) FN

(2) LMETY year

(3) “you”/“he”/“she”

(4) “go”/“goes”

(5) “your”/“her”/“his”

AETR32 Future Auxiliary Benefits – Disadvantageous for Spouse to File While Number Holder in Suspense Due to Work

 (1)   (2)  might qualify for benefits on  (3)  record when  (4)   (5)  working or  (6)   (7)  earnings. However,  (8)  will have to file an application for these benefits. The filing date can make a difference in the amount of benefits we pay.  (9)  should get in touch with us about filing as soon as  (10)   (11)  working or  (12)   (13)  earnings.

Fill-ins:

(1) SN possessive

(2) “wife”/“husband”

(3) PN

(4) “you/“she”/“he”

(5) “stop”/“stops”

(6) “reduce”/“reduces”

(7) “your”/“her”/“his”

(8) SN of spouse *

(9) “She”/“He”

(10) NHSN

(11) “stop”/“stops”

(12) “reduce”/“reduces”

(13) “your”/“her”/“his”

(*) indicates that the fill-ins are manual

AET055 Benefits for All or Part of a Calendar Year Due to Earnings

We are withholding  (1)  of  (2)  benefits for  (3)  because of  (4)  work and earnings.

Fill-ins:

(1) total amount of monthly benefits to be withheld for the year in format $NNNNN.NN

(2) SN possessive/ “your”

(3) month & year in format “Month YYYY”/ month & year and month year in format “Month YYYY and Month YYYY” /month & year through month/year in format “Month YYYY through Month YYYY”

(4) “her”/“his”/“your”

AET057 Earnings are Reported for a Prior, Current or Future Year that is Not a Closed Year

 (1)  estimated that  (2)  would earn $  (3)  in  (4)  .

Fill-ins:

(1) You

(2) SN/you

(3) estimate amount in format $NNNNN.NN

(4) year in the format YYYY

AET058 Earnings are Reported for 2 Prior, Current or Future Years that are Not Closed Years

 (1)  estimated that  (2)  would earn $  (3)  in  (4)  and $  (5)  in  (6)  .

Fill-ins:

(1) You

(2) SN/you

(3) estimate amount in format “$NNNNN.NN”

(4) year in the format “YYYY”

(5) estimate amount in format “$NNNNN.NN”

(6) year in the format “YYYY”

AET059 Earnings are Reported for 1 Or 2 Prior, Current or Future Years that are Not Closed Years and One of the Aforementioned Years is Equal to the BCLM-LMETY

This UTI Will be Used in Tandem with Either AET057 (When 1 Year is Involved) or AET058 (When 2 Years are Involved)

You also said that  (1)  would not earn more than $  (2)   (3)  and would not be active in self-employment in  (4)   (5)   (6)   (7)   (8)   (9)   (10)   (11)  .

Fill-ins:

(1) “you”/“she”/“he”

(2) monthly exempt amount in the format “$$$.¢¢”

(3) If more than one non-service month, add “per month”/otherwise, null

(4) earliest non-service month in the format “April”

(5) “and”/“through”/null

(6) null/non-service month in format “June”

(7) “and”/“through”/null

(8) non-service month in format “July”/null

(9) null/“and”/“through”

(10) null/non-service month in format “August”

(11) show LMETY in format “1988”

AET060 One Year of Temporary Deductions and No Year with Permanent Deductions

 (1)  are withholding  (2)  of  (3)  benefits for  (4)   (5)   (6)   (7)   (8)   (9)   (10)   (11)  because of work and earnings.

Fill-ins:

(1) We

(2) “all”/ Total MBC withheld due to work in format “$$$$.¢¢”

(3) SN possessive

(4) year in format “1988”/month in format “January”

(5) “and”/“through”/null

(6) month in format “April”/null

(7) “and”/null

(8) month in format “June”/null

(9) “and”/“through”/null

(10) month in format “September”/null

(11) year in format “1988”/null

AET061 There are Two Years of Temporary Deductions and No Year with Permanent Deductions

Also, we are withholding  (1)  of  (2)  benefits for  (3)   (4)   (5)   (6)   (7)   (8)   (9)   (10)  .

Fill-ins:

(1) “all”/ Total MBC withheld due to work in format “$NNNN.NN”

(2) SN possessive

(3) year in format “1988”/month in format “January”

(4) “and”/“through”/null

(5) month in format “April”/null

(6) “and”/null

(7) month in format “June”/null

(8) “and”/“through”/null

(9) month in format “September”/null

(10) year in format “1988”/null

AET062 There are Either One or Two Years of Permanent Deductions Due to Work and Earnings

We  (1)  pay  (2)   (3)  benefits for  (4)   (5)   (6)   (7)   (8)   (9)   (10)   (11)   (12)   (13)   (14)   (15)  because  (16)  work.

Fill-ins:

(1) “cannot”

(2) SN

(3) “full”/“any”

(4) year in format “1988”/month and year in format January “1988”/month in format “January”

(5) “and”/“through”/null

(6) month in format “December”/null

(7) “and”/null

(8) month in format “May”/null

(9) “and”/“through”/null

(10) month in format “July”/null

(11) year/null

(12) “and we can pay only”/null

(13) MBC in format “$99,999.99” or “$99,999” (no cents)/null

(14) “for”/null

(15) month and year in the format “August 2008”/null

(16) “your”/“her”/“his”/SN possessive

AET063 There is at Least One Year of Permanent Work Deductions and One Year Where Temporary Work Deductions are Applicable

We  (1)  pay  (2)   (3)  benefits for  (4)   (5)   (6)  because of  (7)  work and earnings. Also, we are withholding  (8)  of  (9)  benefits for  (10)   (11)   (12)  because of work and earnings.

Fill-ins:

(1) “cannot”

(2) SN

(3) “full”/“any”

(4) year/month and year/month

(5) “and”/“through”/null

(6) month and year/month/null

(7) “your”/“her”/“his”

(8) “all”/total MBC in format “$99,999.99” or “$99,999”, no cents

(9) “your”/“her”/“his”

(10) year/month

(11) “and”/“through”/null

(12) month/null

NL 00725.115 “AGE” UTIs – Age

AGE004 Disallowance, Age

 (1)   (2)  not qualify for  (3)  benefits now because, based on  (4)   (5)  ,  (6)  ,  (7)  not yet age  (8)  .

Fill-ins:

(1) SN (First letter capitalized)

(2) “do”/“does”

(3) “retirement”

(4) SN/null

(5) “the date of birth that was given to us”/“correct date of birth”/“date of birth”

(6) month/day/year

(7) “you are”/“she is”/“he is”

(8) “62”/“60”/“50”

AGE005 Disallowance, Child (Age)

 (1)  not qualify for child's benefits because  (2)  : over age 18, and not disabled, and not a full-time elementary or secondary level school student.

Fill-ins:

(1) FN

(2) “she is”/“he is”

AGE006 Age Factor - DOB Not Established

 (1)   (2)  not qualify for  (3)  now because we have not received enough evidence to prove that  (4)  reached age  (5)  . If you can furnish additional proof of  (6)  age, please contact any Social Security office promptly.

Fill-ins:

(1) “You”/SN in format “Mr. Jones”

(2) “do”/“does”

(3) Type of benefit

(4) “you have”/“she has”/“he has”

(5) “62”/“60”/“50”

(6) “your”/“her”/“his”

AGE007 Medicare Disallowance, Age

 (1)  must be at least age 65 to qualify for Medicare. Based on  (2)  ,  (3)  ,  (4)  not old enough.

Fill-ins:

(1) “you”/“she”/“he”

(2) “the date of birth that was given to us”/“[2a] or [2b] date of birth”/“[2a] SN possessive birth date”/“[2b] correct birth date”/null

(3) birth date (MM/DD/YYYY)

(4) “you are”/“she is”/ “he is”

AGE008 Established Date of Birth Different from Alleged

Based on the evidence we have, we have decided that  (1)  correct date of birth is  (2)  .

Fill-ins:

(1) FN

(2) Month/day/year

AGER09 Foreign Birth Record Not Readily Available

To pay benefits more quickly, we use  (1)  as  (2)  date of birth. This date is based on the documents  (3)  gave us. We are still waiting for a copy of the foreign birth record. If the foreign birth record does not agree with the date of birth we used, we may need to revise our decision about  (4)  date of birth. A different date of birth could affect your right to benefits or the amount of your payments. Also, if we paid you too much, you may have to pay us back. When we receive the foreign birth record, we will send you another letter to let you know if there will be a change in your payments.

Fill-ins:

(1) alleged date of birth in the format “Month DD, YYYY” *

(2) “your” or beneficiary's full name in the format “Mr. Jack Jones”

(3) “you”/“she”/“he”

(4) “your”/“her”/“his”

(*) indicates that the fill-ins are manual

NL 00725.120 “ALS” UTIs – Appeals

ALSC02 Caption

Do You Disagree With the Decision?

ALSC05 Caption

How The Hearing Process Works

ALSC08 Caption

It Is Important To Go To The Hearing

ALSC12 Caption

If You Disagree With The Decisions

ALSC26 Caption

About The Appeals

ALSC27 Caption

If You Want To Appeal

ALSC28 Caption

If You Ask For A Reconsideration And A Hearing

ALS023 Appeals Language – Powell Decision

If you do not agree with this decision, you have the right to appeal. We will review  (1)  case and look at any new facts you have. A person who did not make the first decision will decide  (2)  case. We will review the parts of the decision that you think are wrong and correct any mistakes. We may also review the parts of our decision that you think are right. We will make a decision that may or may not be in  (3)  favor.

You have 60 days to ask for an appeal.

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

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

You can file an appeal with any Social Security office. You must ask for an appeal in writing. Please use our “Request for Reconsideration” form, SSA-561-U2. You may go to our website at  (4)  to find the form. You can also call, write, or visit us to request the form. If you need help to fill out the form, we can help you by phone or in person.

Fill-ins:

(1) “your”/name, possessive

(2) “your”/”his”/”her”

(3) “your”/”his”/”her”

(4) www.socialsecurity.gov/online/

ALS040 Appeals Language – Administrative Law Judge

If you disagree with our decision, you have the right to request a hearing. A person who has not seen  (1)  case before will look at it. That person is an Administrative Law Judge. The Administrative Law Judge will review our decisions and look at any new facts you have.

Fill-in:

(1) SN

ALS041 Appeals Language – Res Judicata

If there are no new facts, the judge may find that the application presents the same issues as the prior application, and dismiss the hearings request.

ALS042 Hearing Appeals Period

You have 60 days to ask for a hearing.

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

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

You can file a hearing with any Social Security office. You must ask for a hearing in writing. Please use our “Request for Hearing” form, HA-501. You may go to our website at  (1)  to find the form. You can also call, write, or visit us to request the form. If you need help to fill out the form, we can help you by phone or in person.

If you want to make a request, please contact one of our offices. We can help you complete the required form.

Please read the enclosed pamphlet, “Your Right to an Administrative Law Judge Hearing and Appeals Council Review of Your Social Security Case.” It contains more information about the hearing.

ALS043 Appeals Language – Hearings Request – Living in Foreign Country

You have 60 days to ask for a hearing.

The 60 days start the day after you receive this letter.

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

You can only have a hearing in the United States. You would have to pay any costs for traveling to the United States for the hearing. If you cannot come to the hearing, the ALJ will review your case plus any new information you send us. We will send you a letter about the ALJ's decision.

You have to ask for a hearing in writing. Contact us if you want help.

ALS046 Reconsideration Hearing for Domestic and Foreign Appeals Cases

This action results from reconsideration of your claim and replaces our previous determination.

If you think we are wrong, you have the right to request a hearing. At the hearing, a person who has not seen your case before will look at it. That person is an Administrative Law Judge. In the rest of our letter, we will call this person an ALJ. The ALJ will review those parts of the decision which you believe are wrong. The ALJ will look at any new facts you have and correct any mistakes. The ALJ may also review those parts which you believe are correct and may make them unfavorable or less favorable to you.

ALS047 ALJ Level; Supersedes Previous Determination; Domestic and Foreign

We previously informed you of your appeal rights concerning the administrative law judge's (ALJ) decision. We also informed you of what you must do to have that decision reviewed.

If you believe that we decided any other part of  (1)  case incorrectly, you may request reconsideration on that part of  (2)  case.

Fill-ins:

(1) “your”/”his”/”her”

(2) “your”/”his”/”her”

ALS048 Domestic ALJ Cases; If ALS047 and SCC Present

If you do not agree with this decision, you have the right to appeal. We will review  (1)  case and look at any new facts you have. A person who did not make the first decision will decide  (2)  case. We may also review the parts of the decision that you think are right. We will make a decision that may or may not be in  (3)  favor.

You have 60 days to ask for an appeal.

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

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

You can file an appeal with any Social Security office. You must ask for an appeal in writing. Please use our “Request for Reconsideration” form, SSA-561-U2. You may go to our website at  (4)  to find the form. You can also call, write, or visit us to request the form. If you need help to fill out the form, we can help you by phone or in person.

Fill-ins:

(1) “your”/name, possessive

(2) “your”/”his”/”her”

(3) “your”/”his”/”her”

(4) www.socialsecurity.gov/online/

ALS049 Foreign ALJ Cases; If ALS047 and Consul Code Present

If you want this reconsideration, you must request it not later than 60 days from the date you receive this notice. You may make your request to the Social Security Administration, P.O. Box 17769, Baltimore, Maryland 21235, U.S.A. If additional evidence is available, you should submit it with your request.

If you live in Canada or Mexico, you may also make your request through any Social Security office. Residents of the Philippines may contact the Veterans Affairs Regional office, SSA Division, 1131 Roxas Boulevard, Manila. Residents of all other countries may contact the nearest United States Diplomatic or Consular Office.

ALS054

It is very important that you go to the hearing. If for any reason you can't go, contact the ALJ as soon as possible before the hearing and explain why. The ALJ will reschedule the hearing if you have a good reason.

If you don't go to the hearing and don't have a good reason for not going, the ALJ may dismiss your request for a hearing.

ALS061

This action supersedes our previous determination and is in accordance with the decision on your hearing request. You have already been notified of your appeal rights regarding the decision made on your hearing request and what you must do to have that decision reexamined. If you want this reconsideration, you may request it through any Social Security office. If additional evidence is available, you should submit it with your request. We will review the case and consider any new facts you have. A person who did not make the first decision will decide.

 (1)  case. We will correct any mistakes. We will review those parts of the decision which you believe are wrong and will look at any new facts you have. We may also review those parts which you believe are correct and may make them unfavorable or less favorable to  (2)  .

You have 60 days to ask for an appeal.

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

You must have a good reason for waiting more than 60 days to ask for an appeal.

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

Please read the enclosed pamphlet, “Your Right to Question the Decision Made on Your Social Security Claim”. It contains more information about the appeal.

Fill-ins:

(1) “your”/name, possessive

(2) “you”/“her”/“him”

ALS070 English Translation for Spanish Cover Letter – Awards – Domestic/Foreign Address

If you do not agree with the decision, you may ask to have your case reviewed. But you must request this reconsideration from any Social Security office within 60 days from the date that you receive this notice. You can submit any additional evidence or information you feel would be helpful.

ALS072 English Translation for Spanish Cover Letter – Affirmation of Denial on Reconsideration – Domestic/Foreign Address

If you do not agree with this final decision, you can ask that your claim be reviewed by an Administrative Law Judge of the Office of Disability Adjudication and Review. But you must go to any Social Security office to request the review within 60 days from the date you receive this notice.

The enclosed pamphlet explains your right to appeal.

ALS113

If you disagree with the decisions, you have the right to appeal. A person who did not make the first decision will decide your case. We will review those parts of the decisions you disagree with and will look at any new facts you have. We may also review those parts of the case that you believe are correct and may make them unfavorable or less favorable to you.

ALS073 English Translation for Spanish Cover Letter – Affirmation of Denial on Reconsideration – Mexico Address

If you do not agree with this final decision, you can ask that your case be reviewed by an Administrative Law Judge of the Office of Disability Adjudication and Review. But you must request this review from any Social Security office within 60 days from the date you receive this notice.

ALS121

If you disagree with the nonmedical decisions we made on your case, the appeal is called a reconsideration. Some examples of nonmedical decisions are the amount of your payment, and the month your payment starts. You will not meet with the person who decides your case.

If you disagree with the disability (medical) decision made by the state, the appeal is called a hearing. Some examples of medical decisions are the date your disability started or whether you are still disabled.

ALS122

You have 60 days to ask for an appeal.

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

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

You can file an appeal with any Social Security office. You must ask for an appeal in writing. Please use our “Request for Reconsideration” form SSA-561-U2, or “Request for Hearing” form HA-501. You may go to our website at  (1)  to find the forms. You can also call, write, or visit us to request the forms. If you need help to fill out the forms, we can help you by phone or in person.

ALS123

If you ask for both a reconsideration and a hearing, we will process the hearing first, even if you made the reconsideration request first. When we make our decisions, we will send you letters explaining our decisions on both the reconsideration and the hearing.

ALS125

After we send your case for a hearing, an Administrative Law Judge (ALJ) will mail you a letter at least 20 days before the hearing to tell you its date, time and place. The letter will explain the law in your case and tell you what has to be decided. Since the ALJ will review all the facts in your case, it is important that you give us any new facts as soon as you can.

The hearing is your chance to tell the ALJ why you disagree with the decisions in your case. You can give the ALJ new evidence and bring people to testify for you. The ALJ also can require people to bring important papers to your hearing and give facts about your case. You can question these people at your hearing.

ALSR01 Hearings Level Decision by Someone Other Than an ALJ

We previously informed you of your appeal rights concerning the administrative law judge's (ALJ) decision. We also informed you of what you must do to have that decision reviewed.

If you believe that we decided any other part of  (1)  case incorrectly, you may request reconsideration on that part of  (2)  case. We will review  (3)  case and look at any new facts you have. A person who did not make the first decision will decide  (4)  case. We will review the parts of the decision that you think are wrong and correct any mistakes. We may also review the parts of our decision that you think are right. We will make a decision that may or may not be in  (5)  favor.

You have 60 days to ask for an appeal.

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

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

You can file an appeal with any Social Security office. You must ask for an appeal in writing. Please use our “Request for Reconsideration” form, SSA-561-U2. You may go to our website at  (6)  to find the form. You can also call, write, or visit us to request the form. If you need help to fill out the form, we can help you by phone or in person.

Fill-ins:

(1) “your”/”his”/”her”

(2) “your”/”his”/”her”

(3) “your”/name, possessive

(4) “your”/”his”/”her”

(5) “your”/”his”/”her”

(6) www.socialsecurity.gov/online

NL 00725.125 “APS” UTIs – Applicant Statements

APPC01 Caption

New Application

APP001 New Application

You have the right to file a new application at any time, but filing a new application is not the same thing as appealing this decision. If you disagree with this decision and you file a new application instead of appealing:

you might lose some benefits, or not qualify for any benefits, and

we could deny the new application using this decision, if the facts and issues are the same.

So, if you disagree with this decision, you should file an appeal within 60 days.

NL 00725.130 “ATY” UTIs – Attorney Fee

ATYC01 Caption

Information About  (1)  Fees

Fill-in:

(1) “Lawyer's”/“Representative's”

ATYC02 Caption

How To Ask Us To Review the  (1) 

Fill-in:

(1) “Determination On The Fee Amount”/“Determination On The Fee Agreement”

ATYC03 Caption

Information About Past-Due Benefits Withheld To Pay A Lawyer

ATY052 Attorney or Eligible Representative Not Registered with SSA

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

Fill-ins:

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

(2) lawyer/participant in the demonstration project

(3) first and last name of number holder/you

(4) “lawyer”/“representative”

ATYR01 Attorney Fee Withheld and Paid to Lawyer

We took  (1)  out of  (2)  first check. We are paying this money to the lawyer who helped with this Social Security claim.

Fill-ins:

(1) attorney fee amount *

(2) SN

(*) indicates that the fill-in is manual

ATYR02 Fee Amount Unknown – Past-Due Benefits Unknown

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

Fill-ins:

(1) “your attorney's”/“your representative's”/“the attorney's”/“the representative's”

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

(3) “your attorney”/“your representative”/“the attorney”/“the representative”

(*) indicates that the fill-ins are manual

ATY002 Attorney Involved - Petition

When a lawyer wants to charge for helping with a Social Security claim, we must first approve the fee. We usually withhold 25 percent of past due benefits in order to pay for approved lawyer's fee.

ATYR03 Fee Agreement Subsequently Disapproved and No Past Due Benefits are Available

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

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

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

Fill-ins:

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

(2) “lawyer”/“representative”

(3) Ms. plus BLN/Mr. plus BLN/BGN/BGN plus BLN/“you”

(4) “lawyer”/“representative”

(5) Ms. plus BLN/Mr plus BLN/BGN/BGN plus BLN

(6) “her”/ “his”/ “your”

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

(8) “lawyer”/“representative”

(9) “lawyer”/“representative”

(10) “lawyer”/“representative”

(11) “lawyer”/“representative”

(12) “her”/ “him”/ “you”

(13) “lawyer”/“representative”

(*) indicates that the fill-in is manual

ATY003 Attorney Fees Withheld - Petition

Because a lawyer  (1)  with this claim, we withheld  (2)  from  (3)   (4)  check.

Fill-ins:

(1) “helped”/“may have helped”

(2) amount withheld

(3) “your”/“her”/“his”

(4) “first”

ATYR04 Notify a Beneficiary with a Lawyer or Representative Eligible for Direct Payment that Fee Authorization Cannot Be Released at the Time of Effectuation. (Additional Information Pending)

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

We cannot tell you how much the  (7)  can charge at this time. When processing  (8)  claim we found we needed more information. To decide how much  (9)  benefits will be for  (10)  , we need  (11)   (12)   (13)  . When we get that information, we will decide the amount of  (14)  past-due benefits and send another letter telling you how much the  (15)  can charge. You can help us finish the work on  (16)  claim by taking the information to any Social Security office.

Fill-ins:

(1) “representative”

(2) “representative's”

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

(4) “the benefits due you and your family”/”your benefits”

(5) always use “the”

(6) “representative”

(7) “representative”

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

(9) “her”/“his”/“your”

(10) Month YYYY/Month YYYY and Month YYYY/Month YYYY through Month YYYY

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

A. proof of

B. more information about

(12) “her”/“his”/“your”

(13) Manual fill-in 2 which can include choices of workers' compensation benefits/public disability benefits/workers' compensation and public disability benefits/military service/date of birth/or free format reason*

(14) “her”/“his”/“your”

(15) “representative”

(16) “her”/“his”/“your”

(*) indicates that the fill-in is manual

ATY004 Fee Petition not Received/Approved and Direct Payment Not Waived

We generally must approve any fee  (1)  representative wants to charge for helping with  (2)  Social Security claim. The representative should send us a fee request when he or she has finished all work on the claim. If the representative will not charge a fee, he or she must tell us by sending a signed and dated statement.

Fill-ins:

(1) “your”/name, possessive

(2) “your”/”his”/”her”

ATYR05 Fee Agreement Amount - Auxiliary

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

Fill-ins:

(1) FN possessive

(2) amount

(3) month and year/month and year through month and year

(4) person that signs the fee agreement*

(5) “lawyer”/“representative”

(6) “lawyer”/“representative”

(7) money amount *

(*) indicates that the fill-ins are manual

ATY005 Attorney Fees Withheld - Petition

When the amount of the fee is decided, we will pay the lawyer from the benefits we withheld.

ATY006 Attorney Fees Withheld - Petition

If the approved fee is more than the money we have withheld, the Social Security Administration is not involved in paying the rest of the fee.

ATYR06 Notify a Beneficiary with Representative that Fee Authorization Cannot be Released at Time of Effectuation. (WC/PDB Decision or Appeal of a Denied WC/PDB Claim is Pending)

When a representative wants to charge for helping with a Social Security claim, we must approve the fee.

We cannot tell you how much the representative can charge at this time. When processing  (1)  claim we found we needed more information. To decide how much  (2)  benefits will be for  (3)  , we need  (4)   (5)   (6)  . When we get that information, we will decide the amount of  (7)  past-due benefits and send another letter telling you how much the representative can charge. You can help us finish the work on  (8)  claim by taking the information to any Social Security office.

Fill-ins:

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

(2) “her”/“his”/“your”

(3) Month YYYY/Month YYYY and Month YYYY/Month YYYY through Month YYYY

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

A. proof of

B. more information about

(5) “her”/“his”/”your”

(6) Manual fill-in 2 which can include choices of workers' compensation benefits/public disability benefits/workers' compensation and public disability benefits/military service/date of birth/or free format reason*

(7) “her”/“his”/“your”

(8) “her”/“his”/“your”

(*) indicates that the fill-in is manual

ATY007 Fee Withholding Information - Petition

If the approved fee is less than the money we have withheld, we will send  (1)   (2)  .

Fill-ins:

(1) SN

(2) “the rest of the money”

ATY008 Attorney Appointment Questionable Award

We need more information to decide whether a lawyer represents  (1)  in  (2)  claim for Social Security benefits. We will contact you for this information.

Fill-ins:

(1) SN

(2) “your”/“her”/“his”

ATY009 Attorney Representation Questionable

We need more information to decide whether a lawyer represents  (1)  After we decide this, we will let you know if  (2)   (3)  due any of the money we have withheld.

Fill-ins:

(1) Beneficiary's full name

(2) SN

(3) “is”/“are”

ATY010 Non-Attorney Representative, Fee Not Waived, Award

Your representative must receive approval from the Social Security Administration before a fee can be charged. If the representative wants to charge a fee, a request for approval must be sent to us as soon as all work for  (1)  is finished. If no fee will be charged, we should also be told right away.

Fill-in:

(1) SN

ATY011 Address for Sending Fee Petition

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

Fill-in:

(1) Address to which petition is sent

ATY012 Attorney Waived Option to Direct Payment

However, the lawyer has asked us to send all past due benefits to  (1)  .

Fill-in:

(1) “you”/“her”/“him”

ATYR12 Explanation of Withholding - Auxiliary

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

Fill-ins:

(1) money amount

(2) “your”/name, possessive

(3) “the”

ATY013 Attorney has not Waived Fee, No Past Due Benefits

However, there are no past due benefits available to be paid to the lawyer.

ATY014 Attorney Waived Fee, Award

However, the lawyer has told us that no fee will be charged for services on this Social Security claim. For this reason, no past due benefits have been withheld to pay the lawyer.

ATYR15 Disapproval of Fee Agreement

We cannot approve the fee agreement between you and your  (1)  because  (2)  . Even though we cannot approve the fee agreement, your  (3)  can still charge you a fee for his or her services. If your  (4)  wants to charge a fee, he or she must ask us in writing to approve the amount of the fee. Your  (5)  must give you a copy of his or her fee request and each attachment to the request. If your  (6)  does not want to charge a fee, he or she should tell us.

Fill-ins:

(1) “lawyer”/“representative”

(2) Manual fill-in 1, choice of A through I:

(A) we did not get a written agreement before we decided your claim.

(B) both you and your (representative/lawyer) did not sign the agreement.

(C) it sets a fee amount that is more than 25 percent of past-due benefits or $6000.00.

(D) there are no past-due benefits. We base the fee amount we allow under a fee agreement on your past-due benefits. Since we do not owe you any past-due benefits, we cannot approve the fee agreement.

(E) you appointed more than one representative from a law firm or other business, and all representatives did not sign a single fee agreement (unless the representative(s) who did not sign waived any fee in your case).

(F) you appointed representatives who are not members of the same law firm or other business (unless the representative(s) from the other law firm or business waived any fee in your case).

(G) you discharged a representative, or a representative withdrew from the case, before we favorably decided the claim unless the former representative waived any fee in your case).

(H) your representative died before we issued the favorable decision.

(I) you were declared legally incompetent by a State court and your guardian did not sign the fee agreement.*

(3) “lawyer”/“representative”

(4) “lawyer”/“representative”

(5) “lawyer”/“representative”

(6) “lawyer”/“representative”

(*) indicates that the fill-in is manual

ATY016 Explanation of Attorney Fee Assessment (With Cap)

We are paying the  (1)  from the benefits we withheld. Therefore, we must collect a service charge from him or her. The service charge is 6.3 percent of the fee amount we pay, but not more than $91, which is the most we can collect in each case under the law. We will subtract the service charge from the amount payable to the  (2)  .  (3) 

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

Fill-ins:

(1) “representative”

(2) “representative”

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

(4) “representative”

(5) “representative”

(6) “representative”

ATY018 Non-Attorney Representative, Fee Waived, Award

Your representative told us that a fee will not be charged. If a fee is charged, your representative must receive approval from the Social Security Administration.

ATYR20 Fee Amount – Number Holder Only – Delayed Auxiliary Claims Pending or Expected

We base the amount of the  (1)  fee on the total past-due benefits for you and your family. Your past-due benefits are

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

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

Fill-ins:

(1) “lawyer's”/“representative's”

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

(3) MM/YYYY or MM/YYYY through MM/YYYY

(4) “lawyer”/“representative”

(5) Show amount of the fee in $$$$.¢¢ format.

(6) “lawyer”/“representative”

(7) “lawyer”/“representative”

ATYR22 Fee Amount – Number Holder and Non-Delayed Auxiliary Beneficiary(ies) – Delayed Auxiliary Claims Pending or Expected

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

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

Fill-ins:

(1)

Choice 1 - lawyer's

Choice 2 - representative's

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

(3)

Choice 1 - MM/YYYY

Choice 2 - MM/YYYY through MM/YYYY

(4)

Choice 1 - (current action involves only one auxiliary beneficiary) - insert possessive case of name of auxiliary beneficiary, in the format First Name, Last Name. Example: Henry James.

Choice 2 - (current action involves two or more auxiliary beneficiaries) - insert possessive case of names of auxiliary beneficiaries, in the format First Name, Last Name, (separated by commas and/or “and,” as appropriate). Example: Henry James, William Jones, and Alice James. *

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

(6)

Choice 1 – MM/YYYY

Choice 2 - MM/YYYY through MM/YYYY

(7)

Choice 1 - lawyer

Choice 2 - representative

(8)

Choice 1 - (current action involves only one auxiliary beneficiary) - insert name of auxiliary beneficiary, in the format First Name, Last Name. Example: Henry James.

Choice 2 - (current action involves two or more auxiliary beneficiaries) - insert names of auxiliary beneficiaries, in the format First Name, Last Name, (separated by commas and/or “and,” as appropriate). Example: Henry James, William James, and Alice James. *

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

(10)

Choice 1 - spouse's claim

Choice 2 - other child's claim

Choice 3 - other children's claims

Choice 4 - spouse's and other child's claims

Choice 5 - spouse's and other children's claims *

(11)

Choice 1 - him

Choice 2 - her

Choice 3 - them *

(12)

Choice 1 - lawyer

Choice 2 - representative

(13)

Choice 1 - lawyer

Choice 2 - representative

(*) indicates that the fill-ins are manual

ATY023 Auxiliary's Past-Due Benefit (s) Withheld – SSI Pending

We also withheld  (1)  from  (2)  family's past-due benefits.

Fill-ins:

(1) legal payment deduction amount

(2) “your”/“her”/“his”

ATY079 Claim is Denied and No Fee Agreement Type is Present

 (1)   (2)  must ask us for approval before charging a fee. If  (3)   (4)  wants to charge a fee, a request for approval must be sent to us as soon as all work on this case for  (5)   (6)  is finished.

Fill-ins:

(1) SN possessive

(2) “lawyer”/“representative”

(3) SN possessive

(4) “lawyer”/“representative”

(5) SN

(6) null

ATY080 Attorney/Non-Attorney Representation Questionable, Disallowance

An attorney or other representative must ask us for approval before charging a fee. If  (1)  a representative who wants to charge a fee, a request for approval must be sent to us as soon as all work on this case is finished. If no fee will be charged, we should also be told right away. If the fee is approved, the Social Security Administration will not be involved in paying the fee.

Fill-in:

(1) “you have”/“she has”/“he has”

ATY081 Non-Attorney/Attorney Fee Waived, Disallowance

 (1)  has told us that a fee will not be charged for helping  (2)   (3)  with  (4)  claim.

Fill-ins:

(1) attorney name/representative name

(2) SN

(3)

“and [3a] family members”/null

[3a] “your”/“her”/“his”

(4)

ATY800 Fee Agreement Approval – Number Holder

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

Fill-in:

(1) “lawyer”/“representative”

ATY801 Fee Agreement Approval - Auxiliary

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

Fill-ins:

(1) beneficiary name

(2) “your”/“her”/“his”

(3) “you”/“she”/“he”

(4) “lawyer”/“representative”

(5) beneficiary name

(6) “the”

(7) “lawyer”/“representative”

(8) “lawyer's”/“representative's”

ATY804 Fee Agreement Amount – Number Holder

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

Fill-ins:

(1) “Your”/FN possessive

(2) money amount

(3) month and year/month and year through month and year

(4) “lawyer”/“representative”

(5) pending fee amount

(6) “lawyer”/“representative”

ATY808 Procedure for Review of Fee Under Fee Agreement – Number Holder

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

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

Social Security Administration
Office of Disability Adjudication and Review
Attorney Fee Branch
5107 Leesburg PikeFalls Church, Virginia 22041-3255

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

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

Fill-ins:

(1) “lawyer”/“representative”

(2) “lawyer”/“representative”

(3) “Your family members who have filed claims on your Social Security number (SSN) also may ask us to review the amount of the fee.”/null

(4) “lawyer”/“representative”

(5) “null”

(6) “lawyer”/“representative”

ATY809 Procedure for Review of Fee Under Fee Agreement - Auxiliary

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

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

Social Security Administration
Office of 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 fee is too low.  (5) 

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

Fill-ins:

(1) Beneficiary name

(2) “lawyer”/“representative”

(3) “lawyer”/“representative”

(4) “lawyer”/“representative”

(5) “If we withheld past-due benefits to pay your lawyer's fee, we will

not pay the fee until 15 days pass and no one asks us to review the

amount of the fee.”/null

(6) “lawyer”/“representative”

ATY816 Attorney Responsibilities – Fee Agreement Disapproved

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

If your lawyer:

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

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

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

ATY817 Review of Determination on Fee Agreement

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

Social Security Administration
Office of 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-ins:

(1) “lawyer”/“representative”

(2) “lawyer”/“representative”

ATY825 Fee Agreement Amount – Concurrent Title II/Title XVI – Additional Fee for Title XVI Claim – Number Holders Only

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

Fill-ins:

(1) “lawyer”/“representative”

ATY834 Fee Agreement Amount – Number Holder and Family

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

Fill-ins:

(1) “Your”/FN possessive

(2) money amount

(3) month and year/month and year through month and year

(4) “your”/“her”/“his”

(5) money amount

(6) month and year/month and year through month and year

(7) “lawyer”/“representative”

(8) “you”/SN

(9) “your”/“her”/“his”

(10) the total fee amount

(11) “lawyer”/“representative”

ATY836 Explanation of Withholding – Fee Agreement – Amount Withheld Greater than Fee Amount – SSI Pending – Number Holder

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

Fill-ins:

(1) money amount

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

(3) “the”

ATY838 Explanation of Withholding – Fee Agreement – Amount Withheld Greater than Fee Amount – SSI Pending – Number Holder's Family

Because of the law, we usually withhold 25 percent of the total past-due benefits to pay an approved lawyer's fee. We withheld  (1)  from  (2)  past-due benefits to pay  (3)  lawyer. We also withheld  (4)  from  (5)  family's past-due benefits. We base the amount of the fee  (6)  lawyer can charge on the total past-due benefits due  (7)  and  (8)  family.

Fill-ins:

(1) money amount

(2) “your”/name, possessive

(3) “the”

(4) money amount

(5) “your”/“her”/“his”

(6) “the”

(7) “you”/name

(8) “your”/“her”/“his”

NL 00725.135 “BEN” UTIs – Benefit Information

BEN030 MBA Chart – Shows Changes to MBA on All DIB Awards and RR Certification Awards

The following chart shows  (1)  benefit amount(s) before any deductions or rounding. The amount  (2)  actually receive(s) may differ from  (3)  full benefit amount. When we figure how much to pay  (4)  , we must deduct certain amounts, such as Medicare premiums. We must also round down to the nearest dollar.

Beginning Date

Benefit Amount

Reason

 (5)   (6) 

 (7) 

 (8) 

 (9)  (10)

(11)

(12)

(13)(14)

(15)

(16)

(17)(18)

(19)

(20)

(21)(22)

(23)

(24)

(25)(26)

(27)

(28)

(29)(30)

(31)

(32)

(33)(34)

(35)

(36)

(37)(38)

(39)

(40)

(41)(42)

(43)

(44)

(45)(46)

(47)

(48)

(49)(50)

(51)

(52)

(53)(54)

(55)

(56)

(57)(58)

(59)

(60)

(61)(62)

(63)

(64)

(65)(66)

(67)

(68)

Fill-ins:

(1) your/beneficiary's given name plus “beneficiary's last name possessive

(2) “you”/“she”/ “he”

(3) “your”/“her”/“his”

(4) “you”/“her”/“him”

(5)

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

(7) MBA amount, corresponding to EFD from fill-in 5

(8) Entitlement began/Cost-of-living adjustment/Benefits to another person began or ended/Credit for additional earnings

Fill-ins (9) through (68) follow the logic of fill-ins (5) through (8)

BEN031 DIB Over RIB Entitlement

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

Fill-ins:

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

(2) “your”/“her”/“his”

BEN032 DIB Over RIB Entitlement/Dual Entitlement Involving an Adjustment in Retroactive Benefits

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

Fill-ins:

(1) your/beneficiary's given name/beneficiary's given name plus beneficiary's last name, possessive/Ms. plus beneficiary's last name, possessive/Mr. plus beneficiary's last name, possessive

(2) “first”/”next”

(3) “you”/“she”/“he”

BEN051 Dual Entitlement Benefits Combined in One Check

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

Fill-ins:

(1) “you”/“her”/“him”

(2) “your”/”her”/”his”

BEN052 Benefits Paid in Separate Check

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

Fill-in:

(1) “you”/“her”/“him”

BEN053 Auxiliary Benefits Reduced by Primary Benefits

We are reducing  (1)  benefits as a  (2)  by the amount to which  (3)  entitled on  (4)  own Social Security record. This means  (5)  benefits will now be $  (6)  as a  (7)  plus $  (8)  on  (9)  own record.

Fill-ins:

(1) “your”/“her”/“his”

(2) type of benefit

(3) “you are”/“she is”/“he is”

(4) “your”/“her”/“his”

(5) “your”/“her”/“his”

(6) Money fill-in

(7) type of benefit

(8) Money fill-in

(9) “your”/“her”/“his”

NL 00725.140 “BRR” UTIs – Beneficiary Reporting Responsibilities

BRR004 RSI Responsibilities Information

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

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

Fill-ins:

(1) “Ms.” plus BLN possessive/”Mr.” plus BLN possessive/null plus BGN possessive/null plus FN possessive/“Your”

(2) “she”/“he”/“you”

(3) “her”/“his”/“your”

(4) “Your Payments While You are Outside the United States” (Pub #05-10137)/ “What You Need To Know When You Get Retirement Or Survivors Benefits: (Pub #05-10077)

(5) null

BRR005 Student Responsibilities Information

Please let us know right away if  (1)  no longer a full-time student at an elementary or secondary level school.

Fill-ins:

(1) “you are”/“she is”/“he is”

BRR006 Closed Period

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

Fill-ins:

(1) Ms. plus beneficiary's last name, possessive/Mr. plus beneficiary's last name, possessive/your

(2) “you are”/“she is”/“he is”

(3) “you reach/she reaches/he reaches”

(4) full retirement age, in the format “65”

(5) and/NULL

(6) additional FRA months/NULL

(7) months/NULL

(8) “you reach/she reaches/he reaches”

(9) “you qualify/she qualifies/he qualifies”

BRR008 Representative Payee Appointed

As a representative payee, you have additional responsibilities. They are discussed in the enclosed pamphlet, “A Guide for Representative Payees.”

If you have any questions related to your duties as a representative payee, we invite you to visit our website at  (1)  on the internet.

BRR010 Government Pension Responsibilities

If the amount of  (1)  government pension changes, it may affect  (2)  Social Security benefit. Please let us know about any change right away.

Fill-ins:

(1) “your”/“her”/“his”

(2) “your”/“her”/“his”

BRRR13 SEI Used, Return Not Yet Filed

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

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

Fill-ins:

(1) “your”/“her”/“his”

(2) year *

(3) “you”/“she”/“he”

(4) “you”/“she”/“he”

(5) “your”/“her”/”his”

(*) indicates that the fill-ins are manual

BRR014 RRB Earnings Included

We used  (1)  past railroad work to figure  (2)  Social Security benefit. If  (3)  for the railroad again, please tell us right away if:

 (4)  total railroad work adds up to 120 months, or

 (5)  for the railroad 60 months after 1995.

Fill-ins:

(1) name, possessive/“your”

(2) “your”/“his”/“her”

(3) “you work”/“he works”/“she works”

(4) “Your”/”His”/”Her”

(5) “You work”/“He works”/“She works”

BRR016 Reporting Responsibilities to RRB

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

BRR040 Reporting Responsibilities - General

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

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

Another family member starts working; or

A family member moves out of the household.

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

Fill-ins:

(1) “you”/“she”/“he”

(2) “expect”/“expects”

BRR055 DWB Closed Period

If  (1)  health gets worse and you think  (2)  disabled before  (3)  age 60, you should contact us about applying again for disability benefits.

Fill-ins:

(1) FN possessive

(2) “you were”/“she was”/“he was”

(3) “you reach”/“she reaches”/“he reaches”

BRR057 Number Holder Age 55 to Within 4 Months of Age 62, MOE After 6/80 Based on Onset After 1978 – Auxiliary Benefits Reduced Due to DIB Family Maximum

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

Fill-ins:

(1) FN

(2) “reach”/“reaches”

(3) “your”/“her”/“his”

(4) “you file”/“she files”/“he files”

BRR059 Rights and Responsibilities of People Receiving DIB Benefits

We based our decision on information you gave us. If this information changes, it could affect  (1)  benefits. For this reason, it is important that you report changes to us right away.

We have enclosed a pamphlet, “What You Need To Know When You Get Social Security Disability Benefits.” It tells you what you must report and how to report. Please be sure to read the parts of the pamphlet that tell you what to do if  (2)  to work or if  (3)  health improves.

Fill-ins:

(1) “your”/“his”/“her”

(2) “you go”/“he goes”/“she goes”

(3) “your”/“his”/“her”

BRR060 Medical Improvement – Mother's/Father's Benefits – Rights and Responsibilities

The decisions we made on your claim are based on information you gave us. If this information changes, it could affect your benefits. For this reason, it is important that you report changes right away. We have enclosed a pamphlet, “When You Get Social Security Disability Benefits...What You Need To Know.” It will tell you what must be reported and how to report. Be sure to read the parts of the pamphlet about what to do if your child goes to work or if your child's health improves. Also, remember to tell us if your child is no longer in your care.

NL 00725.145 “CDR” UTIs – Continuing Disability Review

CDR001 Medical Improvement Possible

Doctors and other trained staff decided that  (1)   (2)  disabled under our rules. But, this decision must be reviewed at least once every 3 years. We will send you a letter before we start the review. Based on that review,  (3)  benefits will continue if  (4)  still disabled, but will end if  (5)  no longer disabled.

Fill-ins:

(1) FN

(2) “are”/“is”

(3) “your”/“her”/“his”

(4) “you are”/“she is”/“he is”

(5) “you are”/“she is”/“he is”

CDR002 Medical Improvement Not Expected

Doctors and other trained staff decided that  (1)   (2)  disabled under our rules. However, we must review all disability cases. Therefore, we will review  (3)  case in 5 to 7 years. We will send you a letter before we start the review. Based on that review,  (4)  benefits will continue if  (5)  still disabled, but will end if  (6)  no longer disabled.

Fill-ins:

(1) FN

(2) “are”/“is”

(3) “your”/”her”/“his”

(4) “your”/“her”/“his”

(5) “you are”/“she is”/“he is”

(6) “you are”/“she is”/“he is”

CDR003 Medical Improvement Expected

The doctors and other trained personnel who decided that  (1)  disabled expect  (2)  health to improve. Therefore, we will review  (3)  case in  (4)  . We will send you a letter before we start the review. Based on that review,  (5)  benefits will continue if  (6)  still disabled, but will end if  (7)  no longer disabled.

Fill-ins:

(1) FN “are”/“is”

(2) “your”/“her”/“his”

(3) “your”/“her”/“his”

(4) month and year

(5) “your”/“her”/“his”

(6) “you are”/“she is”/“he is”

(7) “you are”/“she is”/“he is”

CDR024

We decided that  (1)  disabled under our rules. But, this decision must be reviewed once every 3 years. We will send you a letter before we start the review. Based on that review,  (2)  benefits will continue if  (3)  still disabled, but will end if  (4)  no longer disabled.

Fill-ins:

(1) “she is”/“he is”/ “you are”

(2) “her”/“his”/ “your”

(3) “she is”/“he is”/“you are”

(4) “she is”/“he is”/“you are”

CDR025

We decided that  (1)  disabled under our rules. However, we must review all disability cases. Therefore, we will review  (2)  case in 5 to 7 years. We will send you a letter before we start the review. Based on that review,  (3)  benefits will continue if  (4)  still disabled, but will end if  (5)  no longer disabled.

Fill-ins:

(1) “she is”/ “he is”/“you are””

(2) “her”/“his”/ “your”

(3) “her”/“his”/ “your”

(4) “she is”/“he is”/ “you are””

(5) “she is”/“he is”/ “you are”

CDR026

Because we expect  (1)  health to improve, we will review  (2)  case in  (3)  . We will send you a letter before we start the review. Based on that review,  (4)  benefits will continue if

 (5)  still disabled, but will end if  (6)  no longer disabled.

Fill-ins:

(1) “her”/“his”/ “your”

(2) “her”/“his”/ “your”

(3) Month YYYY

(4) “her”/“his”/“your”

(5) “she is”/“he is”/ “you are”

(6) “she is”/“he is”/ “you are”

CDR031

You are entitled to benefits because we decided that your child is disabled under our rules. But, this decision must be reviewed at least once every three years. We will send you or your child a letter before we start the review. Based on that review, your benefits will continue if your child is still disabled, but will end if our child is no longer disabled.

CDR032

You are entitled to benefits because we decided that your child is disabled under our rules. However we must review all disability cases. Therefore, we will review your child's case in 5 to 7 years. We will send you or your child a letter before we start the review. Based on that review, your benefits will continue if your child is still disabled, but will end if your child is no longer disabled.

CDR033

You are entitled to benefits because you have a disabled child in your care. We expect your child's health to improve. Therefore, we will review your child's case in  (1)  . We will send you a letter before we start the review. Based on that review, your benefits will continue if your child is still disabled, but they will end if your child is no longer disabled.

Fill-in:

(1) Month YYYY

NL 00725.150 “CHK” UTIs

CHKC01 Caption

Why We Cannot Pay  (1) 

Fill-in:

(1) “You”/SN

CHKC02 Caption

We Cannot Pay You For Some Months

CHKC03 Caption

Why We Are Delaying Your  (1)  Payments

Fill-in:

(1) Social Security

CHKC04 Caption

We Can Only Pay  (1)  For A Short Time

Fill-in:

(1) “You”/SN

CHKC08 Caption

Why We Cannot Pay  (1)  Beginning  (2) 

Fill-ins:

(1) “You”/SN

(2) month and year

CHKD08 Dictated Text

CHKC09 Caption

Your Benefits

CHKC11 Caption

When We Begin Your Payments

NL 00725.155 “CIC” UTIs – Child In Care

CIC001 Disallowance – No Child in Care

 (1)  not qualify for  (2)  benefits because  (3)  not caring for  (4)  and  (5)  not age  (6)  .

Fill-ins:

(1) “You do”/“She does”/ “He does”

(2) “wife's”/“husband's”/“mother's”/“father's”

(3) “you are”/“she is”/ “he is”

(4) “a child of [4a] who is entitled to Social Security benefits”/“a child who is entitled to benefits on [4b] Social Security record”/“[4c] natural or adoptive child who is entitled to benefits on [4b] Social Security record.”

[4a] NH's SN

[4b] NH's SN

[4c] “your”/“her”/“his”

(5) “you are”/“she is”/ “he is”

(6) “60”/“62”

CIC010 Disabled Minor Child Onset Established Later than Alleged – Spouse MOE Affected

We found that your child became disabled  (1)  . This is different from the date given on the application. You are entitled to benefits because you have a disabled child in

your care. Therefore, the date the child became disabled

affects when your benefits start. You are entitled to benefits beginning  (2)  .

Fill-ins:

(1) date of onset

(2) date of entitlement

CIC011 Disabled Minor Child Given a Closed Period of Disability – Spouse MOE Affected

To be entitled to Social Security Benefits, you must have a child in your care who is also entitled to benefits. And, that child must be under age 16 or disabled.

We have decided that your child became disabled according to our rules on  (1)  and was no longer disabled in  (2)  . Therefore, the first month for which we could pay you benefits is  (3)  . We could pay you for the month the disability ended and the following 2 months. This means that the last month for which you were entitled to benefits was  (4)  .

Fill-ins:

(1) date of onset

(2) ending date of disability

(3) date of entitlement

(4) ending date of entitlement

CIC012 Medical Improvement Possible – Mother's/Father's Benefits – 3 Year Diary

You are entitled to benefits because doctors and other trained staff decided that your child is disabled under our rules. But, this decision must be reviewed at least once every 3 years. We will send you or your child a letter before we start the review. Based on that review, your benefits will continue if your child is still disabled, but will end if your child is no longer disabled.

CIC013 Medical Improvement Not Expected – Mother's/Father's Benefits – 5 Year Diary

You qualify for benefits because doctors and other trained staff decided that you have a disabled child in your care. However we must review all disability cases. Therefore, we will review your child's case in 5 to 7 years. We will send you a letter before we start the review. Based on that review, your benefits will continue if your child is still disabled, but will end if your child is no longer disabled.

CIC014 Medical Improvement Expected – Mother's/Father's Benefits – 6 to 18 Month Diary

You are entitled to benefits because you have a disabled child in your care. The doctors and other trained personnel who made the disability decision expect your child's health to improve. Therefore, we will review your child's case in  (1)  . We will send you a letter before we start the review. Based on that review, your benefits will continue if your child is still disabled. But they will end if your child is no longer disabled.

Fill-in:

(1) date of review in the format Month YYYY

CIC015 Disabled Minor Child Given a Closed Period of Disability – Potential for Future Spouse's (Mother's/Father's Entitlement)

If your child's health gets worse and you think  (1)  is disabled before reaching age 22, you should contact us about applying again for benefits.

Fill-in:

(1) “he/she”

NL 00725.160 “CLO” UTIs – Closeout

CLOC01 Caption

Other Social Security Benefits

CLOC06 Caption

Others Who May Be Eligible For Benefits

CLO001 General Closeout for Disallowances

 (1)  not due any other Social Security benefits. In the future, if you think  (2)  may qualify for benefits from us,  (3)  will need to apply again.

Fill-ins:

(1) “You are”/'He is”/”She is”

(2) “you”/“he”/“she”

(3) “you”/“he”/“she”

CLO002 General Closeout for Awards

 (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-ins:

(1) “This benefit is the only benefit”/“These benefits are the only benefits”

(2) “you”/“he”/“she”

(3) “you”/“he”/“she”

(4) “you”/“he”/“she”

CLO003 Closeout for Lump Sum Awards

We checked to see if  (1)  for any other Social Security benefit on  (2)  record. We found that this is the only one  (3)  can receive from us at this time. In the future, if you think  (4)  might qualify for another benefit from us,  (5)  will need to apply again.

Fill-ins:

(1) “you qualify”/“he qualifies”/ “she qualifies”

(2) NH's FN

(3) “you”/“he”/ “she”

(4) “you”/“he”/“she”

(5) “you”/“he”/“she”

CLO036

 (1)   (2)  may now be eligible for benefits on  (3)  record.  (4)  named the following  (5)  when  (6)  applied for benefits:

Fill-ins:

(1) “Your”/Beneficiary's name (possessive)/

(2) “child”/ “children”

(3) “your”/“his”/ “her”

(4) “You”/“He”/“She”

(5) “child”/“children”

(6) “you”/“he”/ “she”

CLO037

  •  (1) 

  •  (2) 

  •  (3) 

  •  (4) 

  •  (5) 

  •  (6) 

  •  (7) 

  •  (8) 

  •  (9) 

  •  (10) 

Fill-ins:

(1) First child named on DEPC screen

(2) Second child named on DEPC screen

(3) Third child named on DEPC screen

(4) Fourth child named on DEPC screen

(5) Fifth child named on DEPC screen

(6) Sixth child named on DEPC screen

(7) Seventh child named on DEPC screen

(8) Eighth child named on DEPC screen

(9) Ninth child named on DEPC screen

(10) Tenth child named on DEPC screen

CLO038

If  (1)  not filed an application for benefits for the  (2)  , please contact us.

(1) “you have”/“he has”/”she has”

(2) “child”/ “children”

CLOR05 Award Closeout When Second Claim Pending

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-ins:

(1) type of benefit currently being awarded, e.g., retirement *

(2) “you”/“him”/“her”

(3) “you are”/“he is”/“she is”

(4) type of benefit pending, e.g., retirement *

(5) “You”/“He”/“She”

(6) “you”/“he”/“she”

(*) indicates that the fill-ins are manual

CLOR06 Award Closeout When DIB Pending

The  (1)  benefit is the only one to which  (2)   (3)  entitled, with the possible exception of a disability benefit. We will let you know as soon as we decide whether  (4)   (5)  disabled. We will send you another letter to tell you what we decide about  (6)  disability claim.

Fill-ins:

(1) type of benefit currently being awarded *

(2) “you”/SN

(3) “are”/“is”

(4) “you”/“she”/“he”

(5) “are”/“is”

(6) “your”/“her”/“his”

(*) indicates that the fill-ins are manual

CLOR07 Closeout – Other Benefit Possible

We are still looking to see if  (1)  can receive  (2)  benefits.  (3)  cannot receive any other type of benefits based on the application  (4)  filed.

Fill-ins:

(1) “you”/“he”/“she”

(2) type of benefit, e.g., retirement benefit *

(3) “You”/“He”/“She”

(4) “you”/“he”/“she”

(*) indicates that the fill-ins are manual

CLOR11 Closeout of Potential Benefit

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-ins:

(1) type of benefit*

(2) “you”/FN

(3) “are”/“is”

(4) type of benefit *

(5) type of benefit*

(6) “for”/null

(7) SN/null

(8) type of benefit *

(9) “for him”/“for her”/null

(10) type of benefit*

(11) type of benefit *

(*) indicates that the fill-ins are manual

CLOR12 Closeout – Family Benefits Involved

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-ins:

(1) “retirement”/“disability”

(2) “you and your family”/NHFN

(3) “and his”/“and her”/null

(4) “wife's”/“husbands”/“child's” *

(5) “retirement”/“disability”

(6) “for”/null

(7) NHSN/null

(8) “you/your wife”/“your husband”/ “your child” *

(9) “wife's”/“husband's”/“child's” *

(10) “you change your”/“your wife changes her”/“your husband changes his”/“your child changes his/her” *

(11) “you need”/“she needs”/“he needs” *

(12) “you apply”/“your wife applies”/“your husband applies”/“your child applies” *

(13) “retirement”/“disability”

(14) “for”/null

(15) NHSN/null

(16) “wife's”/“husband's”/“child's” *

(*) indicates that the fill-ins are manual

CLOR13 Lump-Sum – Closeout to Other 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-ins:

(1) “you”/FN

(2) “are”/“is”

(3) type of benefit *

(4) “for”/null

(5) SN/null

(6) type of benefit *

(7) “for him”/“for her”/null

(8) type of benefit *

(*) indicates that the fill-ins are manual

CLOR20 Auxiliary Claimant Not Insured On Own Record

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-ins:

(1) required QCs *

(2) acquired QCs *

(*) indicates that the fill-in is manual

NL 00725.165 “COA” UTIs

COA004 Beneficiary is Living in Tax Treaty Country of Switzerland

We will deduct a 15 percent Federal income tax from  (1)  monthly benefits. This is because of a treaty with Switzerland which says we will tax Social Security benefits paid to residents of Switzerland at this rate.

Please let us know if  (2)   (3)  address again.

Fill-ins:

(1) your/beneficiary's give name/beneficiary's full name possessive/Ms. plus beneficiary's last name possessive/Mr. plus beneficiary's last name possessive

(2) “you change”/“she changes”/“he changes”

(3) “your”/“her”/“his”

NL 00725.170 “COL” UTIs – Cost of Living

COL001 Cost of Living Adjustment

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

Fill-ins:

(1) “your”/“her”/“his”

(2) date in format of December 1990

(3) and again in [3a]/null

[3a] Month YYYY/Month YYYY and Month YYYY/Month YYYY, Month YYYY and Month YYYY/Month YYYY, Month YYYY, Month YYYY and Month YYYY

NL 00725.175 “COP” UTIs – Copy of Notice

COPC01 Caption

Other Information

COPD01 Dictated Text

COP001 Copy of Notice to Third Party/ALJ/Attorney or Representative

We are sending a copy of this notice to  (1)   (2)   (3)   (4)   (5)  .

Fill-ins:

(1) claimant name/null

(2) “,”/“and”/null

(3) third party name/ALJ name/null

(4) “and”/null

(5) attorney name/representative name/null

COP002 Copy Cover Notice

Enclosed is a copy of a letter we sent to  (1)  .

Fill-in:

(1) FN

NL 00725.180 “CTZ” UTIs – Citizenship

CTZ005 SMI Only Disallowance

 (1)  did not work long enough under Social Security to qualify for Medicare.

Work under Social Security is figured in credits. Please read the enclosed pamphlet, “How You Earn Social Security Credits,” which explains how the credits are earned.For  (2)  to qualify for Medicare,  (3)  needed to have earned  (4)  credits.  (5)  earned  (6)  credits. These figures are based on  (7)   (8)  date of birth,  (9)  .

In addition,  (10)  cannot qualify for medical insurance because  (11)  neither a United States citizen nor an alien lawfully admitted for permanent residence and residing in the United States for at least 5 years in a row before filing for Medicare.

Fill-ins:

(1) “You”/NHFN

(2) “you”/SN

(3) “you”/NHSN

(4) Quarters of coverage required (QCR) in format 40

(5) “She”/“He”

(6) Quarters of coverage earned

(7) “your”/NHSN possessive

(8) “correct”/null

(9) birthdate in the format, June 10, 1990

(10) “you”/“she”/“he”

(11) “you are”/“she is”/“he is”

CTZ007 Medicare Disallowance - Citizen

 (1)  cannot qualify for Medicare because  (2)  neither a United States citizen nor an alien who was lawfully admitted for permanent residence and residing in the United States for at least five years in a row before filing for Medicare.

 (3)  may be able to buy Medicare coverage in the future.  (4)  can buy Medicare only after  (5)  lived in the United States for five years in a row. These must be the five years right before  (6)  for Medicare. Also as an alien,  (7)  must be lawfully admitted for permanent residence.

Fill-ins:

(1) “You”/“She”/“He”

(2) “you are”/“she is”/“he is”

(3) “You”/“She”/“He”

(4) “You”/“She”/“He”

(5) “you have”/“she has”/“he has”

(6) “you apply”/“she applies”/“he applies”

(7) “You”/“She”/“He”

NL 00725.185 “DAA” UTIs – Drug Addiction and Alcoholism

DAAC01 Caption

About  (1)  Disability

Fill-in:

(1) “Your”/“Her”/“His”

DAAC02 Caption

 (1)  Must Go For Required Treatment

Fill-in:

(1) “You”/“She”/“He”

DAA001 DAA – Award Notice – Reason for Disability is Drug Addiction, Alcoholism or Both

Because  (1)  a contributing factor material to  (2)  disability, the law says that:

 (3)  must go for treatment for  (4)   (5)  when it is available, and make progress in  (6)  treatment or  (7)  payments will be stopped, and

 (8)  can get payments for a total of only 36 months in which treatment is available to  (9)  , and

If we must stop  (10)  payments for 12 months in a row because  (11)  not go for the required treatment or  (12)  not make progress in  (13)  treatment,  (14)  entitlement to benefits will end the next month. In order to receive benefits again,  (15)  will have to file a new application, and

an organization or person, called a representative payee, must receive  (16)  payments for  (17)  . It will be  (18)  payee's duty to manage  (19)  payments and see that  (20)  needs are met, and

If we owe  (21)  for past months, we cannot pay all of the back payments in one lump sum. Instead, we must pay this money over a period of months. The total amount we can pay each month cannot be more than two times  (22)  regular monthly payment amount. By total amount we mean  (23)  monthly payment and any back payment we are paying  (24)  .

Fill-ins:

(1) “drug addiction is”/“alcoholism is”/“drug addiction and alcoholism are”

(2) “your”/“her”/“his”

(3) “you”/“she”/“he”

(4) “your”/“her”/“his”

(5) “drug addiction”/“alcoholism”/“drug addiction and alcoholism”

(6) “your”/“her”/“his”

(7) “your”/“her”/“his”

(8) “you”/“she”/“he”

(9) “you”/“her”/“him”

(10) “your”/“her”/“his”

(11) “You do”/“She does”/“He does”

(12) “do”/“does”

(13) “your”/“her”/“his”

(14) “your”/“her”/“his”

(15) “you”/“she”/“he”

(16) “your”/“her”/“his”

(17) “you”/ “her”/ “him”

(18) “your”/“her”/“his”

(19) “your”/“her”/“his”

(20) “your”/“her”/“his”

(21) “you”/“her”/“him”

(22) “your”/“her”/“his”

(23) “your”/“her”/“his”

(24) “you”/“her”/“him”

DAAR01 Payments End 1/1/97

Because  (1)  a contributing factor material to  (2)  disability, the law says that:

 (3)  must go for treatment for  (4)   (5)  when it is available, and make progress in  (6)  treatment or  (7)  payments will be stopped, and

 (8)  payments will end January 1, 1997 even if  (9)  in treatment, and

An organization or person, called a representative payee, must receive  (10)  payments for  (11)  . It will be  (12)  payee's duty to manage  (13)  payments and see that  (14)  needs are met, and

If we owe  (15)  for past months, we cannot pay all of the back payments in one lump sum. Instead, we must pay this money over a period of months. The total amount we can pay each month cannot be more than two times  (16)  regular monthly payment amount. By total amount, we mean  (17)  monthly payment and any back payment we are paying  (18)  .

Fill-ins:

(1) “drug addiction is”/“alcoholism is”/“drug addiction and alcoholism are”

(2) “your”/“her”/“his”

(3) “you”/“she”/“he”

(4) “your”/“her”/“his”

(5) “drug addiction”/“alcoholism”/“drug addiction and alcoholism”

(6) “your”/“her”/“his”

(7) “your”/“her”/“his”

(8) “your”/“her”/“his”

(9) “you are”/“she is”/“he is”

(10) “your”/“her”/“his”

(11) “you”/“her”/“him”

(12) “your”/“her”/“his”

(13) “your”/“her”/“his”

(14) “your”/“her”/“his”

(15) “you”/“her”/“him”

(16) “your”/“her”/“his”

(17) “your”/“her”/“his”

(18) “you”/“her”/“him”

DAA002 DAA – Award Notice – Treatment Required by Law

We will refer  (1)  to an agency that will decide what treatment is right for  (2)  . That agency will contact  (3)  about  (4)  treatment and when it is available. It will also check whether  (5)  for treatment and report  (6)  progress to us.

The law says that if  (7)  not go for treatment when it is available or  (8)  not make progress in  (9)  treatment, we must stop  (10)  payments. If this happens, we will not begin paying  (11)  right away even when  (12)   (13)  treatments again and  (14)  making progress.

The first time we have to stop paying  (15)  ,  (16)  payments will not begin until  (17)  back in treatment for 2 months in a row.

The second time we have to stop paying  (18)  ,  (19)  payments will not begin until  (20)  back in treatment for 3 months in a row.

The third time we have to stop paying  (21)  ,  (22)  payments will not begin until  (23)  back in treatment for 6 months in a row.

Fill-ins:

(1) “you”/“her”/“him”

(2) “you”/“her”/“him”

(3) “you”/“her”/“him”

(4) “your”/“her”/“his”

(5) “you go”/“she goes”/“he goes”

(6) “your”/“her”/“his”

(7) “you do”/“she does”/“he does”

(8) “do”/“does”

(9) “your”/“her”/“his”

(10) “your”/“her”/“his”

(11) “you”/“her”/“him”

(12) “you start”/“she starts”/“he starts”

(13) “your”/“her”/“his”

(14) “are”/“is”

(15) “you”/“her”/“him”

(16) “your”/“her”/“his”

(17) “you are”/“she is”/“he is”

(18) “you”/“her”/“him”

(19) “your”/“her”/“his”

(20) “you are”/“she is”/“he is”

(21) “you”/“her”/“him”

(22) “your”/“her”/“his”

(23) “you are”/“she is”/“he is”

DAAR06 Payment to Prevent Homelessness Not Paid

We did not pay  (1)  any additional money for housing costs from  (2)  past-due payments. This is because  (3)  .

Fill-ins:

(1) “you”/“her”/“him”

(2) “your”/“her”/“his”

(3)

Choice 1: you did not give us evidence showing you needed the extra money *

Choice 2: you can pay your housing costs from your regular monthly payments *

(*) indicates that the fill-ins are manual

NL 00725.190 “DDD” UTIs – Disability Date Denials

DDD004 New Claim or Reconsideration – Same Issue as Previously Denied Disability Claim

We denied  (1)  previous claim for disability benefits. Our previous decision covered the same issues as this claim. We do not have any new information to change our decision.

Fill-ins:

(1) “your”/FN

DDD005 New Claim or Reconsideration after Prior Substantive Denial Alleging Onset after Insured Status Last Met

The information you gave us does not show that there was any change in  (1)  health before  (2)  . This was when  (3)  last met the earnings requirement for receiving benefits.

Fill-ins:

(1) “your”/FN possessive

(2) date disability last met

(3) “you”/“she”/“he”

DDD006 Widow(er) Files Request for Reconsideration after Substantive Denial – Prior Medical Adjudicated after Prescribed Period Last Expired

The information you gave us does not show that there was any change in  (1)  health before  (2)  . This was the last date  (3)  could qualify for benefits as a disabled  (4)  .

Fill-ins:

(1) “your”/FN possessive

(2) date disability last met

(3) “you”/“she”/“he”

(4) “widow”/“widower”

DDD007 Disabled Child Files Request for Reconsideration after Substantive Denial – Prior Denial Adjudicated after Child Attained Age 22

The information you gave us does not show that there was any change in  (1)  health before  (2)  . This was the last date  (3)  could qualify for benefits as a disabled child.

Fill-ins:

(1) “your”/“her”/“his”

(2) month/day/year=age 22 years

(3) “you”/“she”/“he”

DDD008 Number Holder Not Insured at Alleged Onset or Later – New Claim or Reconsideration Affirms Denial

 (1)   (2)  not qualify for disability benefits because  (3)  not worked long enough under Social Security.

We figure work under Social Security in credits. Please read the enclosed pamphlet, “How You Earn Social Security Credits,” which explains how the credits are earned and how many a person must have to receive benefits.

Since  (4)  not have enough work credits to qualify for benefits, we did not make a decision about whether  (5)  disabled under our rules.

Fill-ins:

(1) “You”/FN

(2) “do”/“does”

(3) “you have”/“she has”/“he has”

(4) “You do”/“She does”/“He does”

(5) “you are”/“she is”/“he is”

DDD009 Widow(er) Prescribed Period Expired Before Alleged Onset – Initial or Reconsideration Decision

We cannot pay  (1)  because  (2)  not disabled within a 7-year period. To qualify,  (3)  would need to meet any one of the following rules:

 (4)  disability began within 7 years after the month that the worker died.

 (5)  disability began within 7 years after the month that  (6)  benefits as a  (7)  ended.

 (8)  disability began within 7 years after the month that  (9)  earlier period of disability ended.

For  (10)  to qualify for benefits,  (11)  disability must have begun before  (12)  , the date  (13)  7-year period ended. You told us  (14)  first became disabled on  (15)  . This date is after the 7-year period.

Since  (16)  not meet the 7-year period requirement, we did not make a decision about whether  (17)  disabled under our rules.

Fill-ins:

(1) “you”/FN

(2) “you were”/“she was”/“he was”

(3) “you”/“she”/“he”

(4) “your”/“her”/“his”

(5) “your”/“her”/“his”

(6) “your”/“her”/“his”

(7) “mother”/“father”

(8) “your”/“her”/“his”

(9) “your”/“her”/“his”

(10) “you”/“her”/“him”

(11) “your”/“her”/“his”

(12) prescribed period end date in format January 1991

(13) “your”/“her”/“his”

(14) “you”/“she”/“he”

(15) alleged onset date

(16) “You do”/“She does”/“He does”

(17) “you are”/“she is”/“he is”

DDDR10 New DWB Application – Prior Denial Under Same Law

 (1)   (2)  not qualify for benefits because this application concerns issues which were decided when an earlier claim was denied. We do not have any information which would cause us to change our earlier decision.

The information you gave us does not show that there was any change in  (3)  health before  (4)  . This was the last day  (5)  could qualify for benefits as a disabled  (6)  .

If you have any new information about  (7)  health on or before  (8)  , you need to give it to us so we can review it.

Fill-ins:

(1) “You”/FN

(2) “do”/“does”

(3) “your”/“her”/“his”

(4) prescribed period end date

(5) “you”/“she”/“he”

(6) “widow”/“widower”

(7) “your”/“her”/“his”

(8) prescribed period end date

DDDR11 Death Within 5 Months of Disability Onset

 (1)  did not qualify for disability benefits because to qualify  (2)  had to be disabled at least 5 full calendar months in a row before death. This requirement is not met because  (3)  was given as the date the disability started and  (4)  as the date of death.

Fill-ins:

(1) NH name

(2) “she”/“he”

(3) alleged onset date

(4) NH's date of death

DDD012 Reporting Health Changes after New Claim or Reconsideration Disallowance

If you have any new information about  (1)  health on or before  (2)  , please send it to us. We need to review it to see if we can change our previous decision.

Fill-ins:

(1) “your”/FN possessive

(2) HA - date last insured/DWB - date prescribed period last met/ DAC - date age 22 attained

DDD017 Number Holder Attained Full Retirement Age in Waiting Period or Earlier Based on Alleged Onset – No Earlier Onset Possible

To qualify for benefits, a person must be disabled for at least 5 full calendar months in a row before reaching full retirement age. You told us that  (1)  became disabled on  (2)  . Our records show that  (3)  reached full retirement age,  (4)   (5)   (6)   (7)  in  (8)  .

Fill-ins:

(1) you/Ms. plus beneficiary's last name/Mr. plus beneficiary's last name

(2) Onset date (month/day/year)

(3) “you”/“she”/“he”

(4) full retirement age, in format “65”

(5) “and”/NULL

(6) additional FRA months in format “2”/NULL

(7) months/NULL

(8) NH's DOB plus full retirement age, in the format June 1998

DDD018 Number Holder Attained Age 65 in Waiting Period or Earlier – Onset Established

To qualify for benefits, a person must be disabled for at least 5 full calendar months in a row before reaching full retirement age. Using the facts you gave us, we found that  (1)  did not become disabled under our rules until  (2)  . Our records show that  (3)  reached full retirement age,  (4)   (5)   (6)   (7)  in  (8)  .

Fill-ins:

(1) you/Ms. plus beneficiary's last name/Mr. plus beneficiary's last name

(2) Current DDO (month/day/year)

(3) “you”/“she”/“he”

(4) full retirement age, in format “65”

(5) and/null

(6) show additional FRA months in format “2”/null

(7) months/null

(8) NH-DOB plus full retirement age, in the format June 1998

NL 00725.195 “DEP” UTIs – Dependents

DEPR07 Disallowance – Child not Dependent

 (1)  not qualify for benefits as a child on  (2)  Social Security record  (3)  . To qualify,  (4)  must have been living with or receiving contributions from  (5)  when:

  •  (6)  applied for benefits, or

  •  (7)  became disabled, or

  •  (8)  became entitled to benefits, or

  •  (9)  died.

The facts we have do not show that any of these requirements is met.

Fill-ins:

(1) “PN does”/“You do”

(2) NH name possessive

(3)

“because she was adopted by someone else”/“because he was adopted by someone else”/ “because you were adopted by someone else”/null

(4) “you”/“she”/he”

(5) SN of NH

(6) “you”/“she”/“he”

(7) SN of NH

(8) SN of NH

(9) “she”/“he”

DEPR08 Disallowance – Adopted Child

 (1)  not qualify for benefits as an adopted child on  (2)  Social Security record because  (3)  did not live with or receive at least half  (4)  support from  (5)  for the last year before  (6)  adoption became final.

Fill-ins:

(1) “You do”/“She does”/“He does”

(2) NH's name

(3) “you”/“she”/“he”

(4) “your”/“her”/“his”

(5) SN of NH

(6) “your”/“her”/“his”

DEPR09 Dependency Requirement - Disallowance

To qualify for child's benefits as a dependent grandchild or step grandchild on  (1)  Social Security record,  (2)  must have:

begun living with  (3)  before age 18; and

lived with  (4)  in the United States and received one-half support from  (5)  throughout the year before  (6)   (7)  .

The facts we have do not show that these requirements are met.

Fill-ins:

(1) NH's name

(2) “you”/FN

(3) “her/him”

(4) “her/him”

(5) “her/him”

(6) “she/he”

(7) “became entitled to disability benefits”/”became entitled to retirement benefits/died/became disabled” *

(*) indicates that fill-in is manual

DEP010 Claims Where a Child is Adopted by the Number Holder's Surviving Spouse but the Dependency Requirement is not Met

 (1)  not qualify for child's benefits on  (2)  Social Security record because  (3)  not living with  (4)  or receiving at least one-half support from  (5)  when  (6)  died.

Fill-ins:

(1) “She does”/“He does”/“You do”

(2) NH-NAME possessive

(3) “she was”/“he was”/“you were”

(4) Ms. Plus NH's SURNAME/Mr. Plus NH's SURNAME

(5) Ms. Plus NH's SURNAME/Mr. Plus NH's SURNAME

(6) “she”/“he”

DEP011 Disallowance – Child Not Living With

 (1)  not qualify for child's benefits on  (2)  Social Security record because  (3)  not living in  (4)  household when  (5)  died.

Fill-ins:

(1) “You do”/“She does”/“He does”

(2) NH's name possessive

(3)

“[3a] natural mother was” or “PN was”

[3a] “your”/“her”/“his”

(4) SN of NH

(5) “she”/“he”

DEPR12 Disallowance – Grandchild Adopted by Surviving Spouse

 (1)  not qualify for child's benefits on  (2)  Social Security record because:

 (3)  parent or stepparent was living in the same household as  (4)  , and

 (5)  receiving support from  (6)  parent or stepparent when  (7)  died.

Fill-ins:

(1) “You do”/“She does”/ “He does”

(2) NH's name

(3) “your”/“her”/“his”

(4) SN of NH

(5) “You were”/“she was”/“he was”

(6) “your”/“her”/“his”

(7) NHSN

DEPR13 Disallowance - Grandchild

To qualify for benefits as a grandchild or step grandchild on  (1)  Social Security record,  (2)  natural or adoptive parents must have been deceased or disabled when:

 (3)  became disabled, or

 (4)  became entitled to benefits, or

 (5)  died.

The facts we have do not show that any of these requirements is met.

Fill-ins:

(1) NH's name

(2) “your”/“her”/“his”

(3) NH's surname

(4) “she”/“he”

(5) “she”/“he”

DEP015 Parent Disallowance – Proof Not Within Time Limit

 (1)  not qualify for parent's benefits because we did not receive proof within the time limit that  (2)  received half of  (3)  support from  (4)  . We needed this proof within 2 years of either the:month  (5)  applied for disability, or date  (6)  died.The facts we have do not show that either requirement is met.

Fill-ins:

(1) “You do”/“She does”/ “He does”

(2) “you”/“she”/“he”

(3) “your”/“her”/“his”

(4) NH's name

(5) “she”/“he”

(6) “she”/“he”

DEP016 Parent Disallowance - Support

 (1)  not qualify for parent's benefits because  (2)  not receiving at least half  (3)  support from  (4)  when  (5)  became disabled or died.

The facts we have do not show that any of these requirements is met.

Fill-ins:

(1) “You do”/“She does”/ “He does”

(2) “you were”/“she was”/“he was”

(3) “your”/“her”/“his”

(4) NH's name

(5) “she/he”

DEP020 Auxiliary Stepchild Disallowance – Dependency Requirements Not Met

To qualify for benefits on a stepparent's record, a child must have been receiving at least one half of his or her support from the stepparent. The child must have been receiving this support  (1)  or, if the stepparent was disabled until entitlement to retirement or disability benefits, when that parent:

last became disabled; or

last became entitled to disability benefits; or

became entitled to retirement insurance benefits.

Fill-in:

(1) when the stepparent died/when he or she applied for benefits

NL 00725.200 “DIB” UTIs – Disability

DIBC01 Caption

The Date You Became Disabled

DIBC02 Caption

The Basis For Our Decision

DIBC03 Caption

Our Decision

DIB001 5 Month Waiting Period – Month of Entitlement

To qualify for disability benefits,  (1)  must be disabled for five full calendar months in a row. The first month  (2)  entitled to benefits is  (3)  .

Fill-ins:

(1) “you”/“FN”

(2) “you are”/“he is”/“she is”

(3) date of entitlement to disability

DIB002 Lead-in Language for Closed Period and Later Onset Date Allowance

We recently told you that  (1)  met the medical requirements to receive Social Security benefits. Now we are writing to tell you that  (2)   (3)  the other requirements. Therefore,  (4)   (5)  for  (6)  beginning  (7)  .

Fill-ins:

(1) “you”/FN

(2) “you”/“she”/“he”

(3) “meet”/“meets”

(4) “you”/“she”/“he”

(5) “qualify”/“qualifies”

(6) “period of disability”/“monthly disability benefits from Social Security”

(7) date of entitlement to disability

DIB003 DIB/DWB/CDB Closed Period

We determined that  (1)  disability ended  (2)  . The first month that we could pay  (3)  benefits was  (4)  . We could pay  (5)  through the month  (6)  disability ended and the next two months. This means that the last month for which  (7)  entitled to benefits was  (8)  .

Fill-ins:

(1) FN possessive/”her”/”his”/”your”

(2) effective date (Date beneficiary went into T8/T6 LAF status in the format “Month YYYY”)

(3) ”her”/“him”/“you”

(4) date of entitlement in the format “Month YYYY)

(5) ”her”/“him”/“you”

(6) “her”/“his”/“your”

(7) “she was”/“he was”/“you were”

(8) effective date (Date beneficiary went into T8/T6 LAF status - 3 months in the format “Month YYYY”)

DIB004 State Agency and Medical Doctor Participation in Decision

Doctors and other trained personnel made the disability decision for us. They work for  (1)  State but used our rules to make their decision.

Fill-in:

(1) “your”/FN possessive

DIB005 Medical Doctor Participation in Non-State Decision

Our doctors and other trained personnel made the disability decision in  (1)  case.

Fill-in:

(1) “your”/FN possessive

DIB006 Benefits Payable up to 12 Months before DIB Filing Date

By law, we can pay benefits no earlier than 12 months before the month of filing. Since  (1)  filed for benefits on  (2)  , monthly payments will begin  (3)  .

Fill-ins:

(1) “you”/FN in format “Mr. Jack Jones”

(2) DOF in format “January 10, 1993”

(3) DOEC in format “April 1994”

DIB014 Benefits Terminated – DIB Cessation

The last month for which  (1)   (2)  entitled to benefits was  (3)  .

Fill-ins:

(1) Number holder's name, possessive/your

(2) family was/wife was/husband was/child was/children were

(3) effective date minus one month in format April 1997

DIB015

The trained staff who decided this case work for the state but used our rules.

NL 00725.205 “DID” UTIs

DID029 Request for Change in Mailing Address/Direct Deposit Information for ALJ Level Award Notices upon Effectuation

Please tell us if  (1)  mailing address or direct deposit information changes. We need this information to deposit  (2)  payments on time and send you important letters about  (3)  payments.

Fill-in:

(1) “your”/FN possessive

(2) “your”/“his”/“her”

(3) “your”/“his”/“her”

NL 00725.210 “DOB” UTIs

DOBC01 Caption

 (1)  Date of Birth

Fill-in:

(1) SN

NL 00725.215 “DSL” UTIs – Disallowance

DSL036 Lead-in for all Reconsideration Disallowances

You asked us to take another look at  (1)  claim for benefits. Someone who did not make the first decision reviewed  (2)  case, including any new facts we received, and found that our first decision was correct.

Fill-ins:

(1) “your”/FN possessive

(2) “your”/“her”/“his”

DSL037 Disallowance of Auxiliary/Survivor Benefits Due to Entitlement to Higher Benefits on Primary Account

 (1)   (2)  not qualify for  (3)  benefits because  (4)   (5)  entitled to an equal or larger benefit on another Social Security record.

Fill-ins:

(1) “you”/“she”/“he”

(2) “do”/“does”

(3) type of benefit

(4) “you”/“she”/“he”

(5) “are”/“is”

DSL038 Disallowance Introduction

We are writing to tell you that  (1)  not qualify for  (2)   (3)  .

Fill-ins:

(1) “you do”/FN “does”

(2) “U.S.”/null

(3) type of benefit (e.g. Medicare, retirement benefits, disability benefits, etc.)

DSL039 Auxiliary Disallowance – Number Holder not Entitled

 (1)  not qualify for Social Security benefits on  (2)  record because  (3)  is not entitled to any benefits.

Fill-ins:

(1) “You do”/“She does”/“He does”

(2) NH's name possessive

(3) “she”/“he”

DSL041 Parent Disallowance – Number Holder Alive

 (1)  not qualify for parent's benefits on  (2)  Social Security record because  (3)  is alive. We can only pay parent's benefits in the event of  (4)  death.

Fill-ins:

(1) “You do”/“She does”/“He does”

(2) NH's name possessive

(3) “she”/“he”

(4) “her”/“his”

DSL045 English Translation for Spanish Cover Letter – Affirmation of Denial on Reconsideration – Domestic/Foreign/Mexico Address

Your claim for Social Security benefits was reviewed as you requested. We regret that we were unable to approve it. A person who did not make the first decision carefully reviewed all of the evidence and information before making this decision.

DSL050 English Translation for Spanish Cover Letter – Denials/Disallowances – Domestic/Foreign Address

We are unable to approve your claim for Social Security benefits. The enclosed explanation in English tells you why. If you need help translating it, ask someone familiar with both English and Spanish to help you. Or contact any Social Security office.

DSL055 English Translation for Spanish Cover Letter – Denials/Disallowances – Mexico Address

We are unable to approve your claim for Social Security benefits. The enclosed explanation in English tells you why. If you need help translating it, ask someone who understands both English and Spanish to help you, or contact any Social Security office or the nearest U.S. Embassy or Consulate.

NL 00725.220 “ENC” UTIs – Enclosure

ENC003 Enclosure Remark for Copy of Cover Notice/Version 1

Enclosure(s):

 (1) 

Fill-in:

(1) Name or names of enclosures

ENC003 Enclosure Remark for Copy of Cover Notice/Version 2

Enclosure(s):

(1)

Letter to (2)

Fill-ins:

Fill-in (1) Name or names of enclosures

Fill-in (2) Addressee

NL 00725.225 “ENT” UTIs – Entitlement

ENTR01 Entitlement Conversions – Award for a Young Wife/Husband, Changes to an Aged Wife/Husband and again Changes to a Divorced Spouse (2 Conversions)

 (1)  entitled to spouse benefits based on having a child in  (2)  care for  (3)  .  (4)  entitled to spouse benefits based on  (5)  age for  (6)  . Beginning  (7)  ,  (8)  entitled to divorced spouse benefits.

Fill-ins:

(1) BGN plus BLN plus “was”/You were

(2) “her”/“his”/“your”

(3) Month YYYY/Month YYYY and Month YYYY/Month YYYY through Month YYYY

(4) Ms. plus BLN plus “was”/Mr. plus BLN plus “was”/You were

(5) “her”/“his”/“your”

(6) Manual fill-in 1 - entitlement period for young wife/husband in the format “Month YYYY” or “Month YYYY and Month YYYY”, or “Month YYYY through Month YYYY”

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

(8) “she is”/“he is”/“you are”

ENTR02 Entitlement Conversions – Award for Aged Wife/Husband, Changes to Divorced Wife/Husband and Changes (Again) Back to an Aged Wife/Husband (2 Conversions)

 (1)  entitled to spouse benefits for  (2)  .  (3)  entitled to divorced spouse benefits for  (4)  . Beginning  (5)  ,  (6)  entitled to spouse benefits again.

Fill-ins:

(1) BGN plus BLN plus “was”/you were

(2) Month YYYY/Month YYYY and Month YYYY/Month YYYY through Month YYYY

(3) Ms. plus BLN plus “was”/Mr. plus BLN plus “was”/you were

(4) Use the value of manual Fill-in 1 - entitlement dates for divorced spouse benefits in the format “Month YYYY” or “Month YYYY and Month YYYY”, or “Month YYYY through Month YYYY”

(5) Month YYYY

(6) “she is”/“he is”/“you are”

ENT009 Lump Sum Award - Introductory

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

Fill-ins:

(1) “You”/FN

(2) “is”/“are”

(3) money amount ($xxx.xx)

(4) NH's name

(5) You will receive the payment around [5a].

[5a] date (mm/dd/yy)

ENTR11 Scope of Application Restricted

You told us that you were not applying for  (1)  benefits. For this reason, we did not consider whether  (2)  might be entitled to these benefits.

Fill-ins:

(1) type of benefit *

(2) “you”/SN

(*) indicates that fill-in is manual

ENT015 DIB Denial Over RIB Entitlement

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

Fill-ins:

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

(2) “you are”/“she is”/“he is”

ENTR18 Child Disability Claim Pending

We are still working on your child's claim for disability benefits. If your child becomes entitled to these benefits, you might receive a larger benefit. When we decide whether or not  (1)  is entitled, we will let you know.

Fill-in:

(1) FN

(*) indicates that fill-in is manual

ENT019 Deferred Award

 (1)   (2)  entitled to monthly  (3)  benefits beginning  (4)  . However, we cannot pay  (5)  until  (6)  .

Fill-ins:

(1) “You”/FN

(2) “is”/“are”

(3) type of benefit

(4) month and year of entitlement

(5) “you”/“her”/“him”

(6) month and year of payment

ENT020 Entitlement to Monthly Benefit - Introductory

 (1)   (2)  entitled to a monthly  (3)  benefit for  (4)   (5)   (6)  .

Fill-ins:

(1) FN

(2) “are”/“is”

(3) type of benefit (e.g., retirement)

(4) DOEC in format “January 1988”

(5) “through”/null

(6) DOST minus one month in format “January 1988”/null

ENT021 Benefits Suspended Due to GPO

However, we cannot pay  (1)  beginning  (2)  because two-thirds the amount of  (3)  government pension is equal to or larger than  (4)  monthly Social Security benefit.

Fill-ins:

(1) SN in format “Mr. Jones” or “you”

(2) Date in format “May 1993”

(3) “your”/“her”/“his”

(4) “your”/“her”/“his”

ENT023 Suspension Months Involved

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

Fill-ins:

(1) “you”/SN

(2) “at this time”/“for”/“beginning”

(3) first month and year for which being suspended/null

(4) “and”/“through”/null

(5) last month and year for which being suspended/null

ENT024 Multiple Suspension Reasons Involved

Although  (1)   (2)  entitled, we cannot pay  (3)  for some months.

Fill-ins:

(1) “you”/FN

(2) “are”/“is”

(3) “your/her/him”

ENTR25 Reduced Benefits

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

Fill-ins:

(1) “You”/SN

(2) “husband's”/“wife's”

ENT026 Award Introduction

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

Fill-ins:

(1) “You”/FN

(2) “are”/“is”

(3) type of benefit

(4) month and year of entitlement or election

ENTR26 Delayed Claimant

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

Fill-ins:

(1) “you”/beneficiary's name

(2) name(s) of delayed claimant(s) possessive *

(*) indicates that fill-in is manual

ENT027 Simultaneous Awards – One Notice Sent

 (1)  entitled to monthly  (2)  benefits beginning  (3)  .  (4)  also entitled to  (5)  benefits on claim number  (6)  beginning  (7)  .

Fill-ins:

(1) “You are”/“She is”/“He is”

(2) disability/retirement

(3) Date fill-in

(4) “You are”/“She is”/“He is”

(5) type of benefit

(6) SSN of survivor/auxiliary claim

(7) Date fill-in

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

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

Fill-ins:

(1) “You are”/“She is”/“He is”

(2) type of benefit

(3) SSN of survivor/auxiliary claim

(4) Date fill-in

(5) “you”/“her”/“him”

ENT029 Simultaneous Awards – Separate Payments (Used on Auxiliary/Survivor Award Notice)

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

Fill-ins:

(1) “you are”/“she is”/“he is”

(2) “your”/“her”/“his”

(3) Date fill-in

(4) “you”/“her”/“him”

ENT030 Suspension Months Involved (2 Periods)

However, we cannot pay  (1)  for  (2)   (3)   (4)  and  (5)   (6)   (7)   (8)  .

Fill-ins:

(1) “You”/SN

(2) month and year

(3) “and”/“through”/null

(4) month and year/null

(5) “beginning”/null

(6) month and year

(7) “and”/“through”/null

(8) month and year/null

ENT031 Suspension Months Involved (3 Periods)

However, we cannot pay  (1)  for  (2)   (3)   (4)  ,  (5)   (6)   (7)  and  (8)   (9)   (10)   (11)  .

Fill-ins:

(1) “you”/SN

(2) month and year

(3) “and”/“through”/null

(4) month and year/null

(5) month and year

(6) “and”/“through”/null

(7) month and year/null

(8) “beginning”/null

(9) month and year

(10) “and”/“through”/null

(11) month and year/null

ENT032 Suspension Months Involved (4 Periods)

However, we cannot pay  (1)  for  (2)   (3)   (4)  ,  (5)   (6)   (7)   (8)   (9)   (10)  and  (11)   (12)   (13)   (14)  .

Fill-ins:

(1) “you”/SN

(2) month and year

(3) “and”/“through”/null

(4) month and year/null

(5) month and year

(6) “and”/“through”/null

(7) month and year/null

(8) month and year

(9) “and”/“through”/null

(10) month and year/null

(11) “beginning”/null

(12) month and year

(13) “and”/“through”/null

(14) month and year/null

ENT034 Suspense Due to Technical Entitlement

However, we cannot pay  (1)  beginning  (2)  because  (3)  entitled to an equal or larger benefit on another record.

Fill-ins:

(1) “you”/“her”/“him”

(2) effective date in format April 1997

(3) “you are”/“she is”/“he is”

ENT035 Future Payments

Any future payments will be based on  (1)  current monthly benefit rate of  (2)  .

Fill-ins:

(1) “your”/SN possessive

(2) MBA

ENT037 Entitlement Introductory Statement

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

Fill-ins:

(1) “your”/FN possessive

(2) type of benefit

(3) “your”/“her”/“his”

(4) date of entitlement

ENT038 No Benefits Payable – Maximum Already Being Paid

We have approved  (1)  application for  (2)  benefits.  (3)  entitlement date is  (4)  . However, we cannot pay  (5)  any benefits because all of the money we can pay on this record is already being paid to  (6)  .

Fill-ins:

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

(2) “spouse's/child's/parent's”

(3) “your”/“her”/“his”

(4) DOEC in format “July 1992”

(5) “you”/“her”/“him”

(6) Number holder's FN

ENT040 LSDP and Survivor Benefit Awarded

 (1)   (2)  entitled to monthly  (3)  benefits beginning  (4)  .  (5)   (6)  also entitled to a Social Security payment of  (7)  because of the death of  (8)  .

Fill-ins:

(1) FN in format “Mr. Jack Jones” or “You”

(2) “are”/“is”

(3) “widow's”/“widower's”/ “child's”/“disabled widow's”/“disabled widower's”/“mother's”/ “father's”

(4) DOEC in format “May 1993”

(5) “you”/“she”/“he”

(6) “are”/“is”

(7) LSAP in format “$999.99”

(8) Number holder's name

ENT041 Entitlement Conversion from a Young Wife/Husband to an Aged Wife/Husband

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

Fill-ins:

(1) BGN plus BLN plus “is”/You are

(2) “her”/“his”/“your”

(3) Month YYYY/Month YYYY and Month YYYY/Month YYYY through Month YYYY

(4) Month YYYY

(5) “she”/“he”/“you”

(6) “her”/“his”/“your”

ENT043 Entitlement Conversion for Either a Mother/Father to a “widow”/”widower” or an Aged Wife/Husband to a Divorced Wife/Husband

 (1)  entitled to  (2)  benefits for  (3)  . Beginning  (4)  ,  (5)  entitled to  (6)  benefits.

Fill-ins:

(1) BGN plus BLN plus “was”/ “You were”

(2) “mother's”/“father's”/“spouse's”

(3) Month YYYY and Month YYYY/Month YYYY through Month YYYY

(4) Month YYYY

(5) Ms. plus BLN plus “is”/Mr. plus BLN plus “is”/“you are”

(6) “widow's”/“widower's”/“divorced wife”/“divorced husband”

ENT048 Period of Suspense (Due to Payee Development) Followed by Payment of Current Benefits Only

We are withholding payment for  (1)  until we decide the best way to make payments.

Fill-ins:

(1) Month YYYY

(2) Month YYYY and Month YYYY

(3) Month YYYY through Month YYYY

ENT050 English Translation for Spanish Cover Letter – Award – Domestic/Foreign Address

Your claim for Social Security benefits has been approved. The enclosed information in English tells you why. If you need help translating it, please ask someone who understands both English and Spanish to help you. Or contact any Social Security office.

ENT055 English Translation for Spanish Cover Letter – Award – Mexico Address

Your claim for Social Security benefits has been approved. The enclosed explanation in English tells you why. If you need help translating it, ask someone who understands both English and Spanish to help you, or contact any Social Security office or the nearest U.S. Embassy or Consulate.

ENT056 Entitled on Another Record

We approved  (1)  claim for  (2)  benefits. However, we cannot pay  (3)  on  (4)  record because  (5)  entitled to an equal or larger benefit on another Social Security record.

Fill-ins:

(1) “your”/“her”/“his”

(2) type of benefit

(3) “you”/“her”/“him”

(4) NH-NAME (possessive)

(5) “you are”/“she is”/“he is”

NL 00725.230 “ERN” UTIs – Earnings

ERN001 Reporting Your Earnings

Because your earnings may affect your Social Security benefits, we need to know how much you earn during the year. Usually, we get that information from:

the earnings your employer reports on your W-2; and

your self-employment earnings reported on your income tax return.

In previous years, Social Security beneficiaries were required to file a separate report with us. Now, you need to report your earnings to us after the end of the year only if:

You are eligible for the monthly earnings test and you earned less than the monthly exempt amount (in that case, you need to tell us so we can pay benefits for that month);

Some or all of the earnings shown on your W-2 were not earned in the year reported;

You earned wages above the exempt amount and you also had a net loss in self-employment;

Your W-2 shows employer-reported wages that you will include on a self-employment tax return (e.g., ministers);

You filed a self-employment tax return but you did not perform any services in your business;

You are a farmer and you get federal agricultural program payments or you have income from carry-over crops;

We withheld some benefits but you had no earnings for the year, (e.g., no wages reported, no self-employment income).

About mid-year, we probably will send you a message asking you to estimate your current and next year's earnings. Your estimates will help us avoid paying you too much or too little in benefits.

SSA Pub 16-012

ERNC01 Caption

Information About  (1)  Earnings Record

Fill-in:

(1) “Your”/SN possessive

ERNC13 Caption

Change(s) to  (1)  Earnings Record

Fill-in:

(1) “Your”/SN possessive

ERNC14 Caption

Reason For The  (1) 

Fill-in:

(1) “Change”/ “Changes”

ERND01 Dictated Text

ERNR09 LAG Earnings Alleged but not Posted

We used  (1)  earnings through  (2)  to figure the benefit amount. Later, we will refigure the benefit to include any earnings  (3)  had after  (4)  .  (5)  will not have to ask us to do this. After we have refigured the benefit amount, we will let you know about any increase.

Fill-ins:

(1) “your”/SN possessive

(2) last year included in the computation *

(3) “you”/“she”/“he”

(4) last year included in the computation *

(5) “you”/“she”/“he”

(*) indicates that the fill-in is manual

ERNR10 Earnings are not Wages

We could not use the money received from  (1)  for  (2)  because  (3)  .

Fill-ins:

(1) employer's name *

(2) year(s) *

(3) “the facts we have do not show that there was an employer-employee relationship”/“the money does not meet our requirements to be considered wages”/“the money was paid as a pension”/“the money was paid because of sickness or accident, and paid more than 6 months after work ended” *

(*) indicates that the fill-in is manual

ERNR11 Wage Determination Pending

We have not used the payments  (1)  received from  (2)  for  (3)  through  (4)  because we have not yet decided whether these payments are wages. We will let you know as soon as we make a decision.

Fill-in:

(1) “you”/SN

(2) employer's name *

(3) year *

(4) year *

(*) indicates that fill-in is manual

ERNR13 Change in Earnings - Chart

We have changed  (1)  earnings record as follows:

 (2) 

Amount Previously Posted

Corrected Amount

   

 (3) 

$  (4) 

$  (5) 

   

 (6) 

 (7) 

 (8) 

   

 (9) 

 (10) 

 (11) 

   

Fill-ins:

(1) SN

(2) “Year”/“Years” *

(3) the year affected *

(4) dollar amount of prior posting *

(5) correct earnings *

(6) second year affected *

(7) dollar amount of prior posting *

(8) correct earnings *

(9) third year affected *

(10) dollar amount of prior posting *

(11) correct earnings *

(*) indicates that fill-in is manual

ERNR14 Reason for Change in Earnings Record

We have changed  (1)  earnings record because  (2)  .

Fill-ins:

(1) “your”/SN possessive

(2) case specific *

(*) indicates that fill-in is manual

ERNR15 Pre-LAG Earnings Added – No Previous Posting

We have corrected  (1)  earnings record to show wages from  (2)  of $  (3)  for  (4)  .

Fill-ins:

(1) “your”/SN possessive

(2) employer's name *

(3) amount *

(4) year *

(*) indicates that fill-in is manual

ERNR16 Pre-LA