Identification Number:
NL 00725 TN 22
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. 22, 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 00725.235 to NL 00725.355 are new sections.

NL 00725.235 “FOB” UTIs - Filing for Other Benefits

NL 00725.240 “FRZ” UTIs - Freeze

NL 00725.245 “FUG” UTIs - Fugitive Felon

NL 00725.250 “FWK” UTIs

NL 00725.255 “GAR” UTIs - Garnishment

NL 00725.260 “GPO” UTIs - Government Pension Offset

NL 00725.265 “HIB” UTIs - Health Insurance Benefits

NL 00725.270 “IDN” UTIs - Identification

NL 00725.275 “INF” UTIs - Reminder/Informational

NL 00725.280 “INS” UTIs - Insured Status

NL 00725.285 “ISC” UTIs - Payment Summary

NL 00725.295 “LIS” UTIs

NL 00725.300 “LSP” UTIs - Lump Sum Payment

NL 00725.305 “MAR” UTIs - Marriage

NL 00725.310 MHP” UTIs - Medicare Health Plan

NL 00725.315 “MIS” UTIs - Miscellaneous

NL 00725.320 “MOE” UTIs - Month of Entitlement

NL 00725.325 “MPD” UTIs - Income Related Monthly Reduction Amount

NL 00725.330 “MSV” UTIs - Military Service

NL 00725.340 “ONS” UTIs - Disability Onset Paragraphs

NL 00725.345 “PAY” UTIs - Payment

NL 00725.350 “PMT” UTIs - Payment Cycling

NL 00725.355 “PRI” UTIs - Prisoner Provisions

<div class="poms">

NL 00725.235 “FOB” UTIs – Filing for Other Benefits

FOB003 Future Benefits – Own Retirement Benefit

You should get in touch with us about 3 months before  (1)   (2)  full retirement age,  (3)   (4)   (5)   (6)  . At that time, you will find out whether  (7)  will be entitled to higher benefits on  (8)  own record.

Fill-ins:

(1) “you”/SN

(2) “reach”/“reaches”

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

(4) “and”/null

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

(6) months/null

(7) “you”/“she”/“he”

(8) “your”/“her”/“his”

FOB005 Future Benefits – “widow”/”widower”

 (1)  may be able to receive  (2)  benefits at age 60, or at age 50 if  (3)  disabled. You should get in touch with us at that time to apply for the benefits.

Fill-ins:

(1) “You”/SN

(2) “widow's”/“widower's”

(3) “you are”/“she is”/“he is”

FOB020 Fully Insured for Retirement Benefits at Age 62

Based on  (1)  earnings and on  (2)  date of birth  (3)  ,  (4)  worked long enough under Social Security to qualify for retirement benefits at age 62.

Fill-ins:

(1) “your”/FN possessive

(2) “the”/ “your”/“her”/“his”

(3) “you gave us”/null

(4) “you have”/“she has”/“he has”

FOBR21 Separate Notices on Dual DIB Claims

If you have not already received a letter with our decision about  (1)  other disability application, you will receive one soon.

Fill-in:

(1) Full Name/your

FOBR22 DIB Payable Before DIB

The disability benefits to which  (1)   (2)  entitled are higher and payable before any retirement benefits to which  (3)  could be entitled. Since no retirement benefits are payable on  (4)  own record while  (5)  receiving disability benefits on the same record, we are taking no action on  (6)  retirement benefit application.

Fill-ins:

(1) “you”/FN

(2) “are”/“is”

(3) “you”/“she”/“he”

(4) “your”/“her”/“his”

(5) “you are”/“she is”/“he is”

(6) “your”/“her”/“his”

NL 00725.240 “FRZ” UTIs – Freeze

FRZ001 Disability Freeze

 (1)   (2)  for a period of disability beginning  (3)  . Although  (4)  will not receive checks during  (5)  period of disability, we will use the period to protect the amount of any benefit we might pay  (6)  family in the future. Future benefits on  (7)  record will be based on  (8)  average earnings. The period of disability ensures that if  (9)  relatively low earnings while disabled, the low earnings will not affect the average.

Fill-ins:

(1) “You”/FN

(2) “qualify”/“qualifies”

(3) onset date

(4) “you”/“she”/“he”

(5) “your”/“her”/“his”

(6) “your”/“her”/“his”

(7) “your”/“her”/“his”

(8) “your”/“her”/“his”

(9) “you have”/“she has”/“he has”

FRZ002 Disability Freeze – Potential Parent's Benefits

If either or both of  (1)  parents were receiving at least half of their support from  (2)  when  (3)  period of disability began, they may be eligible for benefits in the future. You would need to give us proof of this support within two years of the date the period of disability started.

Fill-ins:

(1) “your”/FN possessive

(2) “you”/“her”/“him”

(3) “your”/“her”/“his”

FRZ003 Statutory Blind Number Holder Allowed a Period of Disability (Freeze) but Denied Disability Benefits

We have reviewed  (1)  Social Security claim and find that  (2)  entitled to a period of disability but  (3)  not entitled to Disability Insurance Benefits. We have established a period of disability for  (4)  beginning  (5)  .

To be eligible for disability benefits a person must be unable to engage in substantial gainful activity. It has been determined from the evidence in  (6)  case that the work  (7)  done while disabled shows  (8)  ability to do some type of substantial gainful work. Thus,  (9)  not entitled to these benefits. Under special provisions of the Social Security law concerning blind persons, however,  (10)  entitled to a period of disability regardless of  (11)  ability to work.

The period of disability now established for  (12)  is important. It protects  (13)  right to insurance benefits and the benefit rights of  (14)  dependents and survivors.

Fill-ins:

(1) “your”/FN

(2) “you are”/“she is”/“he is”

(3) “you are”/“she is”/“he is”

(4) “you”/“her”/“him”

(5) onset date (date freeze begins)

(6) “your”/“her”/“his”

(7) “you have”/“she has”/“he has”

(8) “your”/“her”/ “his”

(9) “you are”/“she is”/“he is”

(10) “you are”/“she is”/“he is”

(11) “your”/“her”/“his”

(12) “you”/”her”/“him”

(13) “your”/“her”/“his”

(14) “your”/“her”/“his”

FRZ005 Statutory Blind Number Holder Allowed Freeze – Reporting Responsibilities

The period of disability established for  (1)  will end when  (2)  no longer  (3)  the definition of blindness or when  (4)  full retirement age,  (5)   (6)   (7)   (8)  , whichever occurs first. If before full retirement age,  (9)  unable to continue working because of  (10)  condition, or if  (11)  condition causes  (12)  to substantially reduce  (13)  work activity, you should get in touch with any Social Security office about filing an application for disability insurance benefits.

Fill-ins:

(1) “you”/SN

(2) “you”/“she”/“he”

(3) “meet”/“meets”

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

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

(6) “and”/null

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

(8) months/null

(9) “you become”/ “she becomes”/ “he becomes”

(10) “your”/“her”/“his”

(11) “your”/“her”/“his”

(12) “you”/“her”/“him”

(13) “your”/“her”/“his”

NL 00725.245 “FUG” UTIs – Fugitive Felon

FUGC01 Caption

Information About  (1)  Benefits

Fill-in:

(1) BGN plus BLN possessive/”Your”

FUG058 Suspension of Benefits Due to Outstanding Warrant

We cannot pay benefits to  (1)  because  (2)  an outstanding arrest warrant for a  (3)  .

Fill-ins:

(1) BGN plus BLN /you

(2) “she has”/“he has”/“you have”

(3) “felony crime”/”violation of a condition of probation or parole under Federal or State law”

FUG059 Warrant Information

Our records show that the  (1)   (2)   (3)  issued a warrant for  (4)  arrest for a felony crime or a violation of Federal or State probation or parole on  (5)  .

 (6) 

 (7)   (8) 

 (9)   (10) 

 (11)   (12) 

Social Security cannot provide further information about the warrant.

 (13)   (14)   (15) 

Fill-ins:

(1) Law Enforcement Agency Name

(2) Show the Address on FRATS that corresponds to Law Enforcement Agency Name. The address, if available, will be displayed as a single fill-in with commas after the street address, city, State, and zip./null

(3) Show the Law Enforcement Agency TELEPHONE NUMBER 10 by first showing the word “PHONE” followed by the phone number/null

(4) BGN plus BLN (possessive)/your

(5) Show the WARRANT ISSUE DATE in the format MM/DD/YYYY

(6) The warrant information we have is:/null

(7) Warrant Number:/null

(8) Show the WARRANT NUMBER/null

(9) Show the words “OCA Number:”/null

(10) Show the Originating Case Agency Number/null

(11) Show the words “NCIC NUMBER:”/null

(12) Show the National Crime Information Center Number/null

(13) Show the words “Please contact the”/null

(14) Law Enforcement Agency Name

(15) Show the word “directly.”/null

FUG060 Good Cause Reasons – No Time Limit

We will pay  (1)  if you contact us at any time and can show us that any of the following apply:

The warrant was issued incorrectly in  (2)  name because someone stole  (3)  identity. To prove this, submit a copy of the police report  (4)  filed as a victim of identity theft or another official document from the court or the warrant issuing agency stating that the warrant was erroneously issued in  (5)  name.

 (6)  found not guilty of the criminal offense. To prove this, submit a copy of the court docket indicating  (7)  found not guilty of the criminal charges or a copy of the court decision showing that  (8)  found not guilty of the criminal charges.

The underlying charges relating to the criminal offense were dismissed. To prove this, submit a copy of the court docket indicating charges were dismissed or another official court or law enforcement agency document stating that it dismissed the criminal charges.

The warrant for  (9)  arrest for the criminal offense was withdrawn. To prove this, submit a copy of the court docket or another official document from the issuing agency, indicating the warrant in question was withdrawn.

 (10)  otherwise cleared of the criminal offense. To prove this, submit a copy of the court docket or other court document indicating  (11)  cleared of the criminal charges.

Fill-ins:

(1) Beneficiary's Full name, no possessive/you

(2) “her”/“his”/“your”

(3) “her”/“his”/“your”

(4) “she”/“he”/“you”

(5) “her”/“his”/“your”

(6) “She was”/“He was”/“You were”

(7) “she was”/“he was”/“you were”

(8) “she was”/“he was”/“you were”

(9) ”her”/“his”/“your”

(10) “She was”/“He was”/“You were”

(11) “she was”/“he was”/“you were”

FUG061 Good Cause Reasons – Within 12 Months

If none of the above apply, we also may pay  (1)  benefits if you contact us within 12 months from the date of this letter and can show us that:

The crime for which the warrant was issued or the probation or parole violation was both nonviolent and not drug related and, if a probation or parole violation is involved, the original crime(s) for which  (2)  paroled or put on probation was both nonviolent and not drug related.

And

 (3)  neither been convicted of nor pled guilty to another felony crime since the date of the warrant.

And

The law enforcement agency that issued the warrant reports that it will not extradite  (4)  for the charges on the warrant or that it will not take action on the warrant for  (5)  arrest.

Or

The crime for which the warrant was issued or the probation or parole violation was both nonviolent and not drug related and, if a probation or parole violation is involved, the original crime[s] for which  (6)  paroled or put on probation was both nonviolent and not drug related.

And

 (7)  neither been convicted of nor pled guilty to another felony crime since the date of the warrant.

And

The only existing warrant was issued 10 or more years ago.

And

 (8)  medical condition impairs  (9)  mental capability to resolve the warrant; or  (10)  incapable of managing  (11)  benefits; or  (12)  legally incompetent; or Social Security has appointed a representative payee to handle  (13)  benefits or  (14)  residing in a long-term care facility, such as a nursing home or mental treatment/care facility.

Fill-Ins:

(1) Beneficiary's name, possessive/you

(2) “she was”/“he was”/“you were”

(3) “she has”/“he has”/“you have”

(4) “her”/“him”/“you”

(5) “her”/“his”/“your”

(6) “she was”/“he was”/“you were”

(7) “she has”/“he has”/“you have”

(8) “her”/“his”/“your”

(9) “her”/“his”/“your”

(10) “she is”/“he is”/“you are”

(11) “her”/“his”/“your”

(12) “she is”/“he is”/“you are”

(13) “her”/“his”/“your”

(14) “she is”/“he is”/“you are”

NL 00725.250 “FWK” UTIs

FWK001 Foreign Work Test Applies

If  (1)   (2)  working or if  (3)   (4)  45 hours or less in any month, please let us know right away because  (5)  may be eligible for benefits.

Fill-ins:

(1) “you”/“she”/“he”

(2) “stop”/“stops”

(3) “you”/“she”/“he”

(4) “work”/“works”

(5) “you”/“she”/“he”

NL 00725.255 “GAR” UTIs – Garnishment

GAR003 Garnishment Amount Withheld From PMA

We withheld  (1)  from  (2)  benefits due through  (3)  to pay  (4)  obligation for child support, alimony or court ordered victim restitution.

(1) Money amount

(2) FN possessive/“your”

(3) Date in format “June 2013”

(4) “her”/”his”/”your”

GAR004 Garnishment Ongoing Check Amount

Thereafter, we will withhold  (1)  from  (2)  benefit each month to pay  (3)  obligation for child support, alimony or court ordered victim restitution.

(1) Money amount

(2) FN possessive/“your”

(3) “her”/”his”/”your”

GAR007 Garnishment Withholding Stopped

We changed  (1)  payment to  (2)  beginning  (3)  because we are no longer withholding benefits to pay  (4)  obligation for child support, alimony or court ordered victim restitution.

(1) FN possessive/“your”

(2) Money amount

(3) date in format June 1991

(4) “her”/”his”/”your”

GAR064 Garnishment Amount Withheld From CMA

We withheld  (1)  from  (2)  next scheduled payment which is for  (3)  to pay  (4)  obligation for child support, alimony or court ordered victim restitution.

(1) Money amount

(2) FN possessive/“your”

(3) date in format June 1991

(4) “her”/”his”/”your”

NL 00725.260 “GPO” UTIs – Government Pension Offset

GPOC01 Caption

Other Government Payments Affect Benefits

GPO001 Government Pension Offset (GPO) Explanation

We reduce the Social Security benefits we pay to  (1)  as a  (2)  when  (3)  a Federal, State, or local government pension. The pension must be based on work that is not covered by Social Security. We reduce benefits by two-thirds the amount of the pension. If the two-thirds amount is equal to or more than the Social Security monthly benefit, then we do not pay benefits. There are some exceptions to this rule. The enclosed factsheet, “Government Pension Offset,” explains this reduction in detail.

Fill-in:

(1) “you”/“him”/“her”

(2) “widow”/“widower”/“husband”/“wife”

(3) “you receive”/“he receives”/“she receives”

GPO002 GPO Reduction in Benefits

We are reducing  (1)  benefit beginning  (2)  because  (3)  eligible for a government pension.

Fill-ins:

(1) “your”/SN possessive

(2) date in format June 1991

(3) “you are”/“she is”/“he is”

NL 00725.265 “HIB” UTIs – Health Insurance Benefits

HIBC01 Caption

Information About Medicare

HIBC05 Caption

Why  (1)  Cannot Qualify for Medicare

Fill-in:

(1) “You”/SN

HIBD01 Dictated Text

HIB001 Entitled to HI and/or SMI (This can also be an introductory statement (HIBI01))

 (1)  Medicare  (2)   (3)   (4)   (5)  .

Fill-ins:

(1) “Your”/FN

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

(3) Date in format June 2013

(4) “and Part B (medical insurance starts”

(5) Date in format June 2013

HIB002 New Medicare Card – PIC Change Conversion Award

We will send  (1)  a Medicare card.  (2)  should take this card with  (3)  when  (4)   (5)  medical care. If  (6)   (7)  medical care before receiving the card and  (8)  coverage has already begun, use this letter as proof that  (9)  covered by Medicare.

Fill-ins:

(1) Ms. plus BLN/Mr. plus BLN/BGN/BGN plus BLN/you

(2) “she”/“he”/“you”

(3) “her”/“him”/“you”

(4) “she”/“he”/“you”

(5) need/needs

(6) “she”/“he”/“you”

(7) need/needs

(8) “her”/“his”/“your”

(9) “she is”/“he is”/ “you are”

HIB003 Medicare Disallowance – Filed Before Initial Enrollment Period

 (1)  not entitled to  (2)  under Medicare because  (3)  application was filed too soon.  (4)  may apply again at any time during the period  (5)  through  (6)  .  (7)  must apply in the first three months of this period to make sure Medicare starts in the month  (8)   (9)  age 65.

Fill-ins:

(1) “you are”/“she is”/ “he is”

(2) “medical insurance coverage/medical or hospital insurance coverage”

(3) “your”/“her”/“his”

(4) “you”/“she”/“he”

(5) month and year

(6) month and year

(7) “you”/“she”/“he”

(8) “you”/“she”/“he”

(9) “reach”/“reaches”

HIB004 Medicare Disallowance – Not Timely Filed

 (1)  not entitled to  (2)  under Medicare because  (3)  application was filed too late.  (4)  should have filed before  (5)  . However,  (6)  may apply for coverage again during the next general enrollment period. A general enrollment period takes place in January, February, and March of each year.

Fill-ins:

(1) “you are”/“she is”/ “he is”

(2) “medical insurance coverage”

(3) “your”/“her”/“his”

(4) “you”/“she”/“he”

(5) month and year

(6) “you”/“she”/“he”

HIB005 SMI Premium Billing

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

Fill-ins:

(1) “Your”/“His”/“Her”

(2) Amount of Part B premium in $$$$$.¢¢ format

(3) Date in MM CCYY format

(4) null/“and”/Null

(5) Show the unequal HSA amount that precedes the HSA amount in the format $$$/Show the EFD plus 1 month associated with the HSA amount in the format Month YYYY/ Show the most recent HSA amount in the format $$$/Show the EFD plus 1 month associated with the HSA amount in in the format Month YYYY (will be January plus appropriate YYYY/or other BRI month/YYYY)

HIB008 Premium Deductions

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

Fill-ins:

(1) “your”/“her”/“his”

(2) “next”/month, day and year

HIB009 SMI Premium Billing

We will send your first bill for the premiums within a month. Each bill will be for a 3-month period.

HIB010 SMI Premium Deductions Followed by Suspension

Because  (1)  monthly benefits are stopping, we will bill  (2)  every 3 months for the premiums.

Fill-ins:

(1) “your”/SN possessive/FN possessive/First Name possessive

(2) “you”/“her”/“him”

HIB011 HIB Premium Billing

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

Fill-ins:

(1) “your”/“her”/“his”

(2) “[2a] beginning [2b]/[2c] beginning [2d] and [2e] beginning [2f]

[2a] money amount/null

[2b] Month YYYY/null

[2c] money amount/null

[2d] Month YYYY/null

[2e] money amount/null

[2f] Month YYYY/null

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

HIB013 Medicare Premium Penalty

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

Fill-ins:

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

(2) “you”/“she”/“he”

(3) “you”/“she”/“he”

HIB014 State Buy-in

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

Fill-ins:

(1) “The State of”/null

(2) name of jurisdiction making payments

(3) “your”/“her”/“his”

(4) “in the future”/beginning [4a]

[4a] month and year

HIB015 Premiums Deducted from Civil Service Annuity

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

Fill-ins:

(1) “your”/“her”/“his”

(2) “you”/“her”/“him”

HIB019 Premium Hospital Insurance (HI)

 (1)  cannot get Medicare Part A (hospital insurance) for free. However,  (2)  may be able to buy Medicare Part A for  (3)  a month. Please contact us for more information

Fill-ins:

(1) “You”/FN

(2) “you”/“he”/“she”

(3) monthly premium HI amount

HIB020 Foreign Address

Normally Medicare will only pay for hospital and medical services which  (1)   (2)  in the United States.

Fill-ins:

(1) “you”/“she”/“he”

(2) “receive”/“receives”

HIB021 Subsequent Award – Medicare Not Affected

This letter does not affect  (1)  Medicare benefits.

Fill-in:

(1) “your”/“her”/“his”

HIB022 Coverage Transferred to Another Claim Number

 (1)  still be entitled to  (2)  insurance coverage from Medicare under the claim number we have shown above. We will send  (3)  a new Medicare card with this number on it.

Fill-ins:

(1) “You will”/“She will”/ “He will”

(2) “hospital”/“hospital and medical”

(3) “you”/“her”/“him”

HIBR30 Equitable Relief, Untimely Processing

We did not give  (1)  earlier medical insurance because we did not process it timely. If you want to have these benefits earlier, you can choose medical insurance benefits beginning  (2)  . If you want this benefit to start earlier, you must do the following things within 30 days after the date of this notice:

tell us in writing that you want medical insurance benefits beginning  (3)  ;

pay us $  (4)  . (this covers premiums due from  (5)  through  (6)  );or,

tell us we can withhold this amount from the check.

Fill-ins:

(1) “you”/FN

(2) Earlier SMI entitlement date *

(3) Earlier SMI entitlement date *

(4) Amount of SMI premium from earlier date *

(5) Earlier SMI entitlement date *

(6) Month prior to COM

(*) indicates that fill-in is manual

HIB031 Private Third Party Buy-in

Another individual or organization will pay the premiums for  (1)  Medicare coverage beginning  (2)  . Even though the bill will be sent to them, you are still responsible for seeing that  (3)  premiums are paid. If they decide that they will no longer send the payments, we will start to send the premium notices to you.

Fill-ins:

(1) “your”/SN possessive/FN possessive/First Name possessive

(2) month and year of buy-in

(3) “your”/SN possessive/FN possessive/First Name possessive

HIB032 SMI Option Presumed Refused, Puerto Rico

 (1)   (2)  eligible for medical insurance beginning  (3)  . If you want this coverage or need more information, you should contact your nearest Social Security office.

Fill-ins:

(1) “You”/SN/FN/First Name

(2) “are”/“is”

(3) date of entitlement to SMI - month and year

HIB035 SMI Deductions

We deduct medical insurance premiums from monthly benefit payments. If  (1)   (2)  benefit payments, we will not bill  (3)  for  (4)  premiums.

Fill-ins:

(1) “you”/“she”/“he”

(2) “receive”/“receives”

(3) “you”/“her”/“him”

(4) “your”/“her”/“his”

HIB037 Equitable Relief, Untimely Processing (Used Only with HIBR30)

If you want the benefits beginning  (1)  but find it hard to pay the premium amount in a lump sum, ask us about other ways to pay the money.

Fill-in:

(1) earlier SMI entitlement date - month and year

HIB038 Medicare Disallowance – Crime Against United States

 (1)  cannot qualify for Medicare because  (2)  been convicted of a crime against the security of the United States.

Fill-ins:

(1) “you”/“she”/“he”

(2) “you have”/“she has”/“he has”

HIB042 Claimant Could be or is Covered Under the Federal Employees Health Benefits Act of 1959

 (1)  cannot qualify for Medicare because  (2)  covered under the Federal Employees Health Benefits Act.

Fill-ins:

(1) “you”/“she”/“he”

(2) ““you are”/“she is”/“he is”/you could be/she could be/he could be”

HIB044 Not Entitled, Application Filed too Late

 (1)  not entitled to medical insurance coverage under Medicare because  (2)  application was filed too late.  (3)  should have filed before  (4)  . However,  (5)  may apply for coverage again during the next general enrollment period. A general enrollment period takes place in January, February and March of each year.

Fill-ins:

(1) “you are”/ “she is”/ “he is”

(2) “your”/ “her”/ “his”

(3) “you”/ “she”/ “he”

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

(5) “you”/“she”/“he”

HIB050 Number Holder Age 65 Before End of Waiting Period

You do not qualify for Medicare based on disability because your coverage cannot start before you reach age 65.

To receive Medicare coverage before age 65, a person must be disabled under our rules for 29 months before coverage begins. Based on the date you said you became disabled, coverage could not begin until after you reach age 65. For this reason, we have not decided whether or not you are disabled.

You may qualify for Medicare when you reach age 65, whether or not you are disabled under our rules.

HIB051 Death Within 29 Months of Onset

To receive Medicare coverage before age 65, a person must qualify for disability benefits for 29 months before coverage begins. We were told that  (1)  became disabled on  (2)  , and died on  (3)  . Therefore  (4)  did not qualify for Medicare.

Fill-ins:

(1) NH Name

(2) onset date

(3) date of death - NH

(4) “she”/“he”

HIB052 SMIB Refusal Statement

If you do not want medical insurance, please complete the enclosed card and return it to us in the envelope we have provided. You will need to do this by the date shown on the card. If you decide you do not want the insurance, we will return any premiums that you have paid.

HIBR60 Prisoner Suspension

Generally, Medicare will not pay for hospital or medical items or services  (1)  while  (2)   (3)  . However, you may want to pay  (4)  Medicare medical insurance premiums for two reasons:

The premiums may be higher if you cancel the Medicare medical insurance now and re-enroll after  (5)  released from  (6)  .

 (7)  may not have medical insurance for a period of time after  (8)  released from  (9)  . This is because  (10)  will have to wait until a general enrollment period to re-enroll. A general enrollment period takes place in January, February and March of each year.

If you want to cancel  (11)  medical insurance, please let us know. If you decide to keep Medicare medical insurance, we will bill you for the premium. The first bill we send will be for a 3-month period and will be sent to you shortly before the payment is due.

Fill-ins:

(1) “you receive”/“FN receives”

(2) “you are”/“she is”/“he is”

(3) “imprisoned”/“confined in an institution” *

(4) “your”/“her”/“his”

(5) “you are”/“she is”/“he is”

(6) “prison”/“the institution” *

(7) “you”/“she”/“he”

(8) “you are”/“she is”/“he is”

(9) “prison”/“the institution” *

(10) “you”/“she”/“he”

(11) “your”/“her”/“his”

(*) indicates that the fill-in is manual

HIB062 Not Enrolling in SMI

 (1)   (2)  through  (3)  to sign up for Medicare Part B (medical insurance).

People who have Medicare Part B pay a monthly premium. If  (4)  not sign up for Part B when  (5)  first eligible,  (6)  may have to pay a late enrollment penalty for as long as  (7)  Part B.  (8)  monthly premium may go up 10 percent for each full 12-month period that  (9)  could have had Part B coverage, but did not sign up for it. Usually,  (10)  will not have to pay a late enrollment penalty if  (11)  up during a special enrollment period.

If  (12)  to sign up for Part B after  (13)  ,  (14)  will usually have to wait until the general enrollment period. The general enrollment period takes place in January, February, and March of each year. If  (15)  up in the general enrollment period,  (16)  Part B coverage will start July 1 of the year  (17)  up.

 (18)  may be able to get Part B in a special enrollment period if  (19)  all of these conditions:

  •  (20)  age 65 or older, and

  •  (21)  health insurance under an employer's group plan because  (22)  spouse currently works, and

  •  (23)  had health insurance coverage under that plan since  (24)  became age 65.

NOTE: COBRA and Retiree health coverage do not count as health insurance based on current employment.

 (25)  can sign up in a special enrollment period during these times:

  • At any time  (26)  coverage under that employer's group plan,

    or

  • During the 8 months after the work ends or  (27)  coverage under that plan ends, whichever occurs first.

Deciding when to sign up for Part B may depend on how  (28)  health insurance works with Medicare. For example, a group health plan is usually not the primary insurance if the employer has less than 20 employees. In this case, it is important to have Medicare coverage, and you may want to sign up now.

If  (29)  help deciding what to do, please contact  (30)  employee benefits office or contact us.

Fill-ins:

(1) “You”/FN

(2) “have”/“has”

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

(4) “you do”/“he does”/“she does”

(5) “you are”/“he is”/“she is”

(6) “you”/“he”/“she”

(7) “you have”/“he has”/“she has”

(8) “Your”/“His”/“Her”

(9) “you”/“he”/“she”

(10) “you”/“he”/“she”

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

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

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

(14) “you”/“he”/“she”

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

(16) “your”/“his”/“her”

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

(18) “You”/“He”/“She”

(19) “you meet”/“he meets”/“she meets”

(20) “You are”/“He is”/“She is”

(21) “You have”/“He has”/“She has”

(22) “you or your”/“he or his”/“she or her”

(23) “You”/“He”/“She”

(24) “you”/“he”/“she”

(25) “You”/“He”/“She”

(26) “you or your spouse is working and you have”/ “he or his spouse is working and he has”/”she or her spouse is working and she has”

(27) “your”/“his”/“her”

(28) “your”/“his”/“her”

(29) “you need”/“he needs”/“she needs”

(30) “your”/“his”/“her”

HIB068 Equitable Relief

If  (1)  these benefits earlier,  (2)  can choose  (3)  insurance benefits beginning  (4)  . To start benefits earlier, within 60 days after the date of this notice  (5)  must tell us in writing that  (6)   (7)  insurance benefits beginning  (8)  . In addition,  (9)  must:

pay us  (10)  (this covers premiums due from  (11)  through  (12)  ); or

 (13) 

Fill-ins:

(1) “you want/she wants/he wants”

(2) “you”/“she”/“he”

(3) “hospital/medical/hospital and medical”

(4) HI or SMI NONEQRELST

(5) “you”/“she”/“he”

(6) “you want/she wants/he wants”

(7) “hospital/medical/hospital and medical”

(8) HI or SMI NONEQRELST

(9) “you”/“she”/“he”

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

(11) HI or SMI NONEQRELST

(12) date in format MM/YYYY

(13) tell us we can withhold this amount from the check/tell us to bill you for this amount.

HIB072 Medicare with Railroad Annuity Inv.

Since  (1)   (2)  a railroad beneficiary, the RRB will start to withhold medical insurance premiums from  (3)  Railroad Retirement annuity. If  (4)  not currently receiving a Railroad Retirement annuity, the Social Security Administration will let the RRB know when  (5)  next premium is due. The RRB will send  (6)  a bill for premiums.

Fill-ins:

(1) “you”/FN

(2) “are”/“is”

(3) “your”/“her”/“his”

(4) “you are”/“she is”/ “he is”

(5) “your”/“her”/“his”

(6) “you”/“her”/“him”

HIB074 New Medicare Card Issued

We will send  (1)  a new health insurance card. It will show that  (2)  entitled to  (3)  insurance.

Fill-ins:

(1) “you”/SN/FN/First Name

(2) “you are”/“she is”/ “he is”

(3) “hospital/medical/hospital and medical”

HIB075 Equitable Relief

If  (1)  benefits beginning  (2)  but  (3)  it hard to pay the premium amount in a lump sum, ask us about other ways to pay the money.

Fill-ins:

(1) “you want/she wants/he wants”

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

(3) “find”/“finds”

HIB090 Medicare Terminates, Destroy Card

 (1)  Medicare card will no longer be valid when  (2)   (3)  coverage ends. Please destroy  (4)  card after  (5)  coverage ends.

Fill-ins:

(1) null plus FN possessive/“Your”

(2) “his”/“her”/“your”

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

(4) “his”/“her”/“your”

(5) “his”/“her”/“your”

HIB094 Entitlement Conversion, No Change in HI/SMI

The decision on  (1)   (2)  benefits does not affect  (3)   (4)  coverage.

Fill-ins:

(1) “your”/SN possessive/FN possessive/First Name possessive

(2) “retirement”/“disability”

(3) “your”/“her”/“his”

(4) “hospital insurance/medical insurance/hospital and medical insurance”

HIB095 Earlier HI/SMI Dates

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

Fill-ins:

(1) “your”/SN possessive

(2) “hospital insurance/medical insurance/hospital and medical insurance”

(3) “your”/“her”/“his”

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

(5) “your”/“her”/“his”

HIB096 RRB Cert Beneficiary Entitled to HI/SMI

 (1)  entitled to Medicare. The Railroad Retirement Board (RRB) has jurisdiction of  (2)  Medicare. RRB will issue  (3)  Medicare card. If  (4)  not receive  (5)  Medicare card in 45 days, you should contact the local office of the Railroad Retirement Board.

Fill-ins:

(1) “she is”/ “he is”/ “you are”

(2) “her”/“his”/ “your”

(3) “her”/“his”/“your”

(4) “She does”/“He does”/“You do”

(5) “her”/“his”/“your”

HIB103 Third Party Buy-in, Closed Period

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

Fill-ins:

(1) The State of/null

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

(3) “your”/SN possessive

(4) “hospital/medical/hospital and medical”

(5) date(s), in format “Month YYYY” or “Month YYYY and Month YYYY” or “Month YYYY through Month YYYY”

HIB108 Third Party, Group Payer – Billing Terminates

The organization that was paying  (1)  Medicare  (2)  insurance premium will no longer pay it after  (3)  .  (4)  must pay the premium beginning  (5)  .

Fill-ins:

(1) “your”/SN possessive/FN possessive/First Name possessive

(2) “hospital/medical/hospital and medical”

(3) date in format “MM/YYYY”

(4) “you”/“she”/“he”

(5) date in format “MM/YYYY”

HIB119 Third Party, Group Payer – Confirmation of Billing Arrangement

 (1)  recently arranged for an organization to pay  (2)  Medicare  (3)  insurance premium. Although we will send the bills to this organization,  (4)  responsible for seeing that they are paid.

If this organization decides to stop paying  (5)  premium, we will again send the bills to  (6)  .

If there is any other change in  (7)  Medicare premium, we will let  (8)  know.

Fill-ins:

(1) “You”/SN possessive/FN possessive/First Name possessive

(2) “your”/“her”/“his”

(3) “hospital/medical/hospital and medical”

(4) “you are”/“she is”/“he is”

(5) “your”/“her”/“his”

(6) “you”/“her”/“him”

(7) “your”/SN possessive

(8) “you”/“her”/“him”

HIB121 ESRD Awards (Introductory Paragraph)

We are writing to tell you that  (1)  entitled to Medicare coverage because of  (2)  kidney condition.

Fill-ins:

(1) NHFN plus “is”/you are

(2) “your”/“her”/“his”

HIB122 Entitlement Conversion Cases with Previous HI and/or SMI

 (1)  already entitled to  (2)  because  (3)   (4)  . The date[s] of  (5)  entitlement to  (6)  did not change.

Fill-ins:

(1) “You are”/SN plus “is”

(2) “hospital insurance/medical insurance/hospital and medical insurance”

(3) “you are”/“he is”/“he is”

(4) disabled/over age 65/enrolled based on a kidney condition

(5) “your”/“her”/“his”

(6) “hospital insurance/medical insurance/hospital and medical insurance”

HIB124 Awards – Previous SMI

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

Fill-ins:

(1) “you”/“she”/“he”

(2) “has”/“have”

(3) current HI date of entitlement in format “July 1999”

HIB125 DIB Awards, Beneficiary Previously Entitled to HI/SMI Based on ESRD

If  (1)  disability ends,  (2)  may still qualify for Medicare because of  (3)  kidney condition if:

 (4)  disability ends less than 12 months after  (5)  last regular dialysis, or

 (6)  disability ends less than 36 months after  (7)  last kidney transplant.

Fill-ins:

(1) “your”/“her”/“his”

(2) “you”/“she”/“he”

(3) “your”/“her”/“his”

(4) “your”/“her”/“his”

(5) “your”/“her”/“his”

(6) “your”/“her”/“his”

(7) “your”/“her”/“his”

HIB126 ESRD Awards, Beneficiary Previously Receiving Premium HI

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

Fill-in:

(1) “You”/SN

HIB127 ESRD Awards, Beneficiary Previously Receiving Premium HI

But,  (1)  will still have to pay premiums for medical insurance. The monthly medical insurance premium rate is $  (2)  .

Fill-ins:

(1) “you”/“she”/“he”

(2) [2a] beginning [2b]./[2c] beginning [2d] and $[2e] beginning [2f]

[2a] money amount

[2b] date, in format “Month YYYY”

[2c] money amount

[2d] date, in format “Month YYYY”

[2e] money amount

[2f] date, in format “Month YYYY”

HIB128 ESRD Awards

Medicare coverage based on  (1)  kidney condition will end the last day of the  (2)  month after the month  (3)   (4)  unless before then  (5)  again:

get(s) a kidney transplant, or

begin(s) regular dialysis.

Fill-ins:

(1) “your”/“her”/“his”

(2) 12th/36th

(3) “you”/“she”/“he”

(4) got your transplant/got her transplant/got his transplant/stops dialysis/stop dialysis

(5) “you”/“she”/“he”

HIB129 ESRD Awards, Previous Premium HI or SMI

Even if  (1)  no longer entitled to free hospital insurance based on  (2)  kidney condition,  (3)  will still be entitled to Medicare because  (4)   (5)  .

Fill-ins:

(1) “you are”/“she is”/ “he is”

(2) “your”/“her”/“his”

(3) “you”/“she”/“he”

(4) “you are”/“she is”/”he is”

(5) over age 65/disabled/a Railroad Retirement board beneficiary

HIB130 Closed Period ESRD Award

Our records show that  (1)   (2)  in  (3)  . Therefore,  (4)  Medicare coverage based on  (5)  kidney condition ends the last day of  (6)  .

Fill-ins:

(1) “you”/“she”/“he”

(2) “stopped regular dialysis”/“received a kidney transplant”

(3) date in the format “July 1999”

(4) “your”/“her”/“his”

(5) “your”/“her”/“his”

(6) date in the format “July 1999”

HIB132 Closed Period Award for RRB Beneficiary

However, since the Railroad Retirement Board [RRB] handles  (1)  hospital and medical insurance  (2)  Medicare coverage will continue unless the RRB tells  (3)  they are stopping  (4)  coverage.

Fill-ins:

(1) “your”/“her”/“his”

(2) “your”/“her”/“his”

(3) “you”/“her”/“him”

(4) “your”/“her”/“his”

HIB136 ESRD Closed Period Awards

Let us know right away if  (1)  regular dialysis again or  (2)  a kidney transplant so  (3)  can file a new claim for Medicare coverage based on  (4)  kidney condition.

Fill-ins:

(1) “you resume”/“she resumes”/“he resumes”

(2) “get”/“gets”

(3) “you”/“she”/“he”

(4) “your”/“her”/“his”

HIB151 Closed Period Third Party Buy-in

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

Fill-ins:

(1) “you”/“she”/“he”

(2) date, in format “Month YYYY”

HIB152

 (1)   (2)  through  (3)  to enroll in Medicare Part B (medical insurance).

People who have Part B pay a monthly premium. If  (4)  not sign up for Part B when  (5)  first eligible,  (6)  may have to pay a late enrollment penalty for as long as  (7)  Part B.  (8)  monthly premium may go up 10 percent for each full 12-month period that  (9)  could have had Part B coverage, but did not sign up for it. Usually,  (10)  will not have to pay a late enrollment penalty if  (11)  up during a special enrollment period.

If  (12)  to sign up for Part B after  (13)  ,  (14)  will usually have to wait until the general enrollment period. The general enrollment period takes place in January, February, and March of each year. If  (15)  up in the general enrollment period,  (16)  Part B coverage will start July 1 of the year  (17)  up.

 (18)  may also be able to sign up during a special enrollment period.  (19)  can do this if  (20)  one of the conditions listed below:

  •  (21)  covered under a group health plan through  (22)  current work or  (23)  spouse's current work,

  •  (24)  covered under a large group health plan through  (25)  current work or any family member's current work.

 (26)  may sign up for medical insurance at any time  (27)  covered under the group health plan. However,  (28)  may wait and sign up during the 8-month period that begins when the work ends or  (29)  coverage under the plan ends, whichever occurs first.  (30)  may also sign up if the type of plan  (31)  changes.

NOTE: COBRA and Retiree health coverage do not count as health insurance based on current employment.

Deciding when to sign up for Part B may depend on how  (32)  health insurance works with Medicare. For example, a group health plan is usually not the primary insurance if the employer has less than 20 employees. In this case, it is important to have Medicare coverage, and you may want to sign up now.

If  (33)  help deciding what to do, please contact  (34)  employee benefits office or contact us.

Fill-ins:

(1) FN/“You”

(2) “have”/“has”

(3) Hospital Insurance Start Date (HI-START) plus 3 months in Month CCYY format

(4) “you do”/“he does”/“she does”

(5) “you are”/“he is”/“she is”

(6) “you”/“he”/“she”

(7) “you have”/“he has”/“she has”

(8) “Your”/“His”/“Her”

(9) “you”/“he”/“she”

(10) “you”/“he”/“she”

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

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

(13) Hospital Insurance Start Date (HI-START) plus 3 months in Month CCYY format

(14) “you”/”he”/”she”

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

(16) “your”/”his”/”her”

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

(18) FN / “You”

(19) “You”/”He”/”She”

(20) “you meet”/”he meets”/”she meets”

(21) “You are”/”He is”/”She is”

(22) “your”/”his”/”her”

(23) “your”/”his”/”her”

(24) “You are”/”He is”/”She is”

(25) “your”/”his”/”her”

(26) “You”/”He”/”She”

(27) “you are”/”he is”/”she is”

(28) “you”/”he”/”she”

(29) “your”/”his”/”her”

(30) “You”/”He”/”She”

(31) “you have”/”he has”/”she has”

(32) “your”/”his”/”her”

(33) “you need”/”he needs”/”she needs”

(34) “your”/”his”/”her”

HIB157

If this notice is for a child under age 19 who is not covered by health insurance, there is a Children's Health Insurance Program that may help. To find out more, you can look on the Internet at  (1)  or call, toll free, 1-877-KIDS-NOW

(1-877-543-7669). The number connects you to your state program.

Fill-in:

1. www.insurekidsnow.gov

HIB170 ESRD, Monthly Benefits Terminating but HI/SMI Continuing

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

There is a monthly premium for  (4)  medical insurance. Because we are stopping monthly checks, we will bill  (5)  every 3 months for the premiums.

Fill-ins:

(1) “you are”/SN plus “is”

(2) “you”/“she”/“he”

(3) “your”/“her”/“his”

(4) “your”/“her”/“his”

(5) “you”/“her”/“him”

HIB171 ESRD, Monthly Benefits Terminating but HI/SMI with State Buy-in is Continuing

Even though  (1)  no longer receiving monthly checks,  (2)  will still have hospital and medical insurance coverage under Medicare. Please keep  (3)  Medicare card. The State where  (4)  will continue to pay the premiums for  (5)  medical insurance coverage under Medicare.

Fill-ins:

(1) “you are”/SN plus “is”

(2) “you”/she”/“he”

(3) “your”/“her”/“his”

(4) “you live/she lives/he lives”

(5) “your”/“her”/“his”

HIB186 Information Regarding Income Related Monthly Adjustment Amount (IRMAA)

IMPORTANT: A new law changes how premiums for Medicare Part B are calculated for some higher income beneficiaries, generally individuals with incomes higher than  (1)  and couples with incomes higher than  (2)  . Social Security will be contacting the Internal Revenue Service, and if we determine that  (3)  to pay a higher premium, we will send  (4)  a notice explaining our decision, and the higher amount will be effective  (5)  . For more information, visit www.socialsecurity.gov on the Internet or call us toll-free at 1-800-772-1213 (TTY 1-800-325-0778).

Fill-ins:

(1) Show the IRMAA level 1 yearly amount for singles

(2) Show the IRMAA level 1 yearly amount for couples

(3) “he has”/“she has”/ “you have”

(4) “her”/”him”/”you”

(5) SMI start date in format July 2013

HIB215 Closed Period DIB Award and HI/SMI Terminates

Since  (1)  no longer entitled to monthly Social Security benefits, we are stopping  (2)   (3)  insurance coverage under Medicare.  (4)   (5)  insurance coverage ends on the last day of  (6)  . Please destroy  (7)  Medicare card after the coverage ends.

Fill-ins:

(1) “you are”/“she is”/ “he is”

(2) “your”/“her”/“his”

(3) “hospital and medical”/“hospital”

(4) “your”/“her”/“his”

(5) “hospital and medical”/“hospital”

(6) HI termination date in the format May 1999

(7) “your”/“her”/“his”

HIB249 SMI Equitable Relief and Retroactive VSMI Exists

If you want your medical insurance to start earlier, you can choose to have it start in  (1)  . To start your medical insurance earlier, you must do the following things within 60 days after the date of this notice:

  • tell us in writing that you want medical insurance beginning  (2)  ;

    • AND

  • pay us  (3)  or tell us we can withhold this amount from your check. This amount covers the premiums due from  (4)  through  (5)  .

If you would find it hard to pay the premium amount you would owe in a lump sum, ask us about other ways to pay the premium.

If you choose to have your medical insurance start in  (6)  , your current monthly premium will be  (7)  . If you do not choose the earlier date, your monthly premium will be  (8)  .

(1) date in format July 2013

(2) date in format July 2013

(3) Money amount

(4) date in format July 2013

(5) date in format July 2013

(6) date in format July 2013

(7) Money amount

(8) money amount

NL 00725.270 “IDN” UTIs – Identification

IDN016 Proof of Identity Not Provided

We cannot approve  (1)  claim because  (2)  did not give us proof of  (3)  identity.  (4)  responsible for providing evidence to support  (5)  claim.

Fill-ins:

(1) “your”/”BN, possessive”

(2) “you”/“he”/“she”

(3) “your”/ “his”/”her”

(4) “You are”/”BN is”

(5) “your”/ “his”/”her”

NL 00725.275 “INF” UTIs – Reminder/Informational

INFC02 Caption

Your Responsibilities

INFC03 Caption

What You Need To Do

INFC07 Caption

Things To Remember For The Future

INFC09 Caption

Rules For Lawful Presence In The U.S.

INFD02 Dictated Text

INFD07 Dictated Text

NL 00725.280 “INS” UTIs – Insured Status

INS010 Number Holder Not Insured

 (1)  did not work long enough under Social Security for  (2)  to receive benefits.

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 and how many a person needs to receive benefits.

For  (3)  to qualify for benefits,  (4)  needed to have earned:

a total of  (5)  credits, or

at least 6 credits in the period beginning  (6)  .

 (7)  earned a total of only  (8)  credits and only  (9)  credits in the period beginning  (10)  . These figures are based on  (11)   (12)  date of birth,  (13)  and  (14)   (15)  date of death,  (16)  .

Fill-ins:

(1) NH's FN

(2) “you”/“her”/“him”

(3) “you”/SN/FN/First Name

(4) NH's FN

(5) QCR in format 40

(6) 36 months from NH's DOD and enter month and year of first month in the quarter in the format May 1944

(7) “She/He”

(8) QCE in format 10

(9) total numeric value of credits earned for period determined in fill-in 6

(10) Same as fill-in 6

(11) “her”/“his””

(12) “corrected”/null

(13) NH birthdate in format July 10, 1999

(14) “her”/“his”

(15) “corrected”/null

(16) NH date of death in format July 24, 1999

INS011 Number Holder Uninsured Survivor Disallowance (D/F Only)

 (1)  did not work long enough under Social Security for  (2)  to receive benefits.

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 and how many a person needs to receive benefits.

For  (3)  to qualify for benefits,  (4)  needed to have earned  (5)  credits.  (6)  earned  (7)  credits. These figures are based on  (8)   (9)  date of birth,  (10)  and  (11)   (12)  date of death,  (13)  .

Fill-ins:

(1) NH's FN

(2) “you”/“her”/“him”

(3) “you”/SN/FN/First Name

(4) NH's FN

(5) QCR in format 40

(6) “She”/“He”

(7) QCE in format 10

(8) “her”/“his”

(9) “corrected”/null

(10) NH's birth date in format July 10, 1999

(11) “her”/“his”

(12) “corrected”/null

(13) NH's date of death in format July 24, 1999

INS012 Claimant Uninsured for Medicare

 (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)  .

Fill-ins:

(1) NH's FN

(2) SN

(3) NH's SN

(4) required QC's in format 40

(5) She/He

(6) earned QC's in format 10

(7) NH's SN possessive

(8) correct/null

(9) NH's birth date in format mm/dd/yy.

INS014 Auxiliary (Life) Claim Disallowed – Number Holder Uninsured

 (1)  did not work long enough under Social Security for  (2)  to receive benefits.

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 and how many a person needs to receive benefits.

For  (3)  to qualify for benefits,  (4)  needed to have earned  (5)  credits.  (6)  earned  (7)  credits. These figures are based on  (8)   (9)  date of birth,  (10)  .

Fill-ins:

(1) NH's FN

(2) “you”/“her”/“him”

(3) “you”/beneficiary's SN/FN/First Name

(4) NH's FN

(5) QCR in format 40

(6) “She”/“He”

(7) QCE in format 10

(8) “her”/“his”

(9) “corrected”/null

(10) NH's date of birth

INS015 LSDP Disallowance – Number Holder Not Insured

 (1)  did not work long enough under Social Security for  (2)  to qualify for the lump sum death payment.

For  (3)  to qualify for the lump sum death payment,  (4)  needed to have earned:

a total of  (5)  credits, or

at least 6 credits in the period beginning  (6)  .

 (7)  earned a total of only  (8)  credits and only  (9)  credits in the period beginning  (10)  . These figures are based on  (11)   (12)  date of birth,  (13)  and  (14)   (15)  date of death,  (16)  .

Fill-ins:

(1) NH's FN

(2) “you”/FN

(3) “you”/FN

(4) NH's SN

(5) QCR in format 40

(6) Subtract 36 months from NH's DOD and enter first month and year of quarter

(7) “She”/“He”

(8) QCE in format

(9) Total numeric value of credits earned during period determined in fill-in (6)

(10) same as fill-in (6)

(11) “her”/“his”

(12) “corrected”/null

(13) NH birth date

(14) “her”/“his”

(15) “corrected”/null

(16) NH date of death

INS016 Number Holder Uninsured – Medicare (Individual Other Than Number Holder Filed)

 (1)  did not work long enough under Social Security for  (2)  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  (3)  to qualify for Medicare,  (4)  needed to have earned a total of  (5)  credits.

 (6)  earned a total of  (7)   (8)  and still needs  (9)  more. These figures are based on  (10)  date of birth,  (11)  .

Fill-ins:

(1) NH's FN

(2) “you”/FN

(3) “you”/“her”/“him”

(4) NH's SN

(5) quarters needed in the format “40”

(6) NH's SN

(7) quarters earned in the format “40”

(8) “credit”/“credits”

(9) additional quarters needed

(10) NH's SN possessive

(11) NH's date of birth

INS020 Expiration of Disability Insured Status

We consider  (1)  disabled under our rules, if  (2)  a medical condition that:

  • keeps  (3)  from doing any type of substantial gainful work, and

  • has lasted or is expected to last for at least 12 months in a row or result in death.

  •  (4)  also must have earned enough credit for work under Social Security.

  • The last date when  (5)  had enough credits is  (6)  . We did not find that  (7)  disabled before this date.

Please read the enclosed pamphlet, “How You Earn Credits,” which tells you how to earn credits and how many credits  (8)  to get benefits.

Fill-ins:

(1) “you”/FN

(2) “you have”/“he has”/ “she has”

(3) ”you”/“him”/“her”

(4) “You”/FN

(5) “you”/“he”/“she”

(6) Date last insured in format MM, YYYY

(7) “you were”/“he was”/ “she was”

(8) “you need”/“he needs”/ “she needs”

INS021 Disallowance – Not Insured

 (1)   (2)  not worked long enough under Social Security to receive benefits  (3)  .

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 and how many a person needs to receive benefits.

To qualify for benefits,  (4)   (5)  a total of  (6)  work credits.  (7)   (8)  earned  (9)  credits, and still  (10)   (11)   (12)  more. These figures are based on  (13)   (14)   (15)  .

Fill-ins:

(1) “You”/NH SN

(2) “have”/“has”

(3) “on your own record”/“on her own record”/“on his own record”

(4) “you”/“she”/“he”

(5) “need”/“needs”

(6) required QCs

(7) “you”/“she”/“he”

(8) “have”/“has”

(9) earned QCs

(10) “need”/“needs”

(11) quarters still needed

(12) “credit”/“credits”

(13) “your”/NH's FN possessive

(14) “corrected date of birth”/“date of birth”/null

(15) NH's date of birth

NL 00725.285 “ISC” UTIs – Payment Summary

ISCH01 Heading

Payment Summary

NL 00725.295 “LIS” UTIs

LIS003 Claimant Dies In or Before DIB Waiting Period

We are sorry to learn of  (1)  loss. Please accept our sincere sympathy.

(1) “your”

NL 00725.300 “LSP” UTIs – Lump Sum Payment

LSP003 LSDP Disallowance – Eligible Spouse was Living in the Same Household as the Number Holder

 (1)  not qualify for the lump-sum death payment because we are paying it to  (2)   (3)  . Since  (4)  was living with  (5)  when  (6)  died,  (7)  qualifies for the payment.

Fill-ins:

(1) You do/beneficiary's SN plus “does”/beneficiary's FN plus “does”/beneficiary's First Name plus “does”

(2) NH-FN possessive

(3) “widow”/“widower”

(4) “she”/“he” (refers to surviving “widow”/ “widower”)

(5) NH's SN

(6) “she”/“he” (refers to NH)

(7) “she”/“he” (refers to surviving “widow”/ “widower”)

LSP004 LSDP Disallowance – Child Beneficiary Meets Requirements but Eligible Widow(er) Survivor Exists

 (1)  not qualify for the lump-sum death payment because we are paying it to  (2)   (3)  . Since  (4)  was living with  (5)  when  (6)  died, or entitled to benefits on  (7)  record for the month of death,  (8)  qualifies for the payment.

Fill-ins:

(1) “You do”/beneficiary's First Name plus “does”/beneficiary's FN plus “does”

(2) NH-FN possessive

(3) “widow”/“widower”

(4) “she”/“he” (refers to the “widow”/”widower”)

(5) NH's SN

(6) “she”/“he” (refers to the NH)

(7) “her”/“his” (refers to the NH)

(8) “she”/“he” (refers to the surviving “widow”/”widower”)

LSP007 LSDP Disallowance – Surviving Spouse

 (1)  not qualify for the lump-sum death payment as a surviving spouse on  (2)  Social Security record. To qualify  (3)  must have been living with  (4)  at the time of  (5)  death or eligible for regular Social Security benefits on  (6)  record.

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

Fill-ins:

(1) “You do”/“She does”/ “He does”

(2) NH FN possessive

(3) “you”/“she”/ “he”

(4) NH SN

(5) “her”/“his”

(6) “her”/“his”

LSPR08 LSDP Disallowance – Outside U.S. and not U.S. Citizen

 (1)  not qualify for the lump-sum death payment because  (2)  :

was not a United States citizen, and

died outside the U.S., and

was not able to receive benefits because  (3)  was outside the U.S.

Fill-ins:

(1) “You do”/“She does”/“He does”

(2) FN of NH

(3) “she”/“he”

LSP009 LSDP Disallowance

 (1)  not qualify for the lump-sum death payment because  (2)  not  (3)   (4)  or child.

Fill-ins:

(1) “You do”/“She does”/“He does”

(2) “you are”/“she is”/“he is”

(3) NH's FN possessive

(4) “widow”/“widower”

LSP011 LSDP Disallowance – Not Within Time Limit

 (1)  not qualify for the lump-sum death payment because  (2)  did not apply for it within 2 years of  (3)  death. Our records show that  (4)  died on  (5)  and that  (6)  applied on  (7)  .

Fill-ins:

(1) “You do”/“She does”/ “He does”

(2) “you”/“she”/“he”

(3) NH's FN possessive

(4) “she”/“he”

(5) NH's date of death

(6) “you”/FN

(7) CL application date

LSP012 LSDP Disallowance - Child

 (1)  not qualify for the lump-sum death payment as a child on  (2)  Social Security record. To qualify,  (3)  must have been eligible for regular Social Security benefits on  (4)  record at the time of  (5)  death.

Fill-ins:

(1) “You do”/ “She does”/ “He does”

(2) NH's FN possessive

(3) “you”/“she”/“he”

(4) NH's SN possessive

(5) “her”/“his”

LSP013 Child Awarded Share of LSDP Along with Another Child(ren)

There are  (1)  children who were eligible for benefits on  (2)  Social Security record in the month  (3)  died. Each child is due an equal share of the lump-sum death payment. The amount we have shown above is  (4)  share.

Fill-ins:

(1) enter number of PICs in format “two”

(2) Number holder's FN possessive

(3) “she”/“he”

(4) FN possessive/“your”

NL 00725.305 “MAR” UTIs – Marriage

MARD01 Dictated Text

MAR001 Disallowance - Divorce

To qualify for benefits as a divorced  (1)  ,  (2)  must meet one of these requirements:

  •  (3)  and  (4)  must have been married under the laws of  (5)  , where  (6)  lived when  (7)  , or

  •  (8)  the same rights as a spouse to inherit from  (9)  under the laws of  (10)  .

The facts we have do not show that either requirement is met.

Fill-ins:

(1) “widow”/“widower”/“wife”/“husband”/“mother”/“father”/“disabled widow”/“disabled widower”

(2) “you”/“she”/“he”

(3) You/SN

(4) NH's FN

(5) State name of residence at time of death or time of filing

(6) NHs SN

(7) “[7a] died”/“[7b] applied for benefits”

[7a] “she”/“he”

[7b] “you”/SN

(8) “you have”/ “she has”/”he has”

(9) NHs SN

(10) same as fill-in (5)

MARD02 Dictated Text

MAR002 Disallowance – Marriage not Valid

To qualify for benefits as a  (1)  ,  (2)  must meet one of these requirements:

  •  (3)  and  (4)  must  (5)  married under the laws of  (6)  , where  (7)  lived when  (8)  , or

  •  (9)  went through a ceremony which  (10)  thought resulted in a legal marriage with  (11)  and  (12)  still living with  (13)  when  (14)  , or

  •  (15)  the same rights as a spouse to inherit from  (16)  under the laws of  (17)  .

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

Fill-ins:

(1) “wife”/“husband”/“widow”/“widower”/“mother”/“father”/“disabled widow”/“disabled widower”

(2) “you”/“she”/“he”

(3) “you”/SN

(4) NH's FN

(5) “have been”/“be”

(6) State name

(7) NH's SN

(8) “[8b] died”/“[8a] applied for benefits”

[8a] “she/he”

[8b] “you”/“she”/“he”

(9) “you”/SN

(10) “you”/“she”/“he”

(11) NH's SN

(12) “you were”/“she was”/“he was”

(13) “her/him”

(14) “PN died”/“PN applied for benefits”

[14a] “she/he”

[14b] “you”/“she”/“he”

(15) SN has/you have

(16) NH's SN

(17) State name

MAR007 Disallowance Due to Remarriage – Widow(er)

To qualify for benefits as a  (1)  ,  (2)  must meet one of these requirements:

 (3)  not married now, or

 (4)  remarried after age 60, or

 (5)  remarried after age 50 while  (6)  entitled to benefits as a disabled  (7)  .

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

Fill-ins:

(1) “widow”/“widower”

(2) “you”/“she”/”he”

(3) “you are”/ “she is”/“he is”

(4) “you”/“she”/“he”

(5) “you”/”she”/”he”

(6) “you were”/“she was”/ “he was”

(7) “widow”/“widower”

MAR010 Disallowance – Child Married

 (1)  not qualify for child's benefits because  (2)  married.

Fill-ins:

(1) “You do”/“She does”/ “He does”

(2) “you are”/“she is”/ “he is”

MAR011 Disallowance – Parent Married

 (1)  not qualify for parent's benefits because  (2)  married after  (3)  death.

Fill-ins:

(1) “You do”/ “She does”/”He does”

(2) “you”/“she”/ “he”

(3) NH FN possessive

MARR12 Medicare Disallowance – Divorced Spouse

To qualify for Medicare as a divorced  (1)  ,  (2)  must meet one of these requirements:

 (3)  and  (4)  must have been married under the laws of  (5)  , where  (6)  lived when  (7)  , or

 (8)  the same rights as a spouse to inherit from  (9)  under the laws of  (10)  .

The facts we have do not show that either requirement is met.

Fill-ins:

(1) “wife”/“husband”

(2) “you”/“she”/“he”

(3) “you”/“she”/“he”

(4) NH's FN

(5) State name *

(6) NH's SN

(7) “she died”/“he died”/“she applied for Medicare”/“he applied for Medicare”/“you applied for Medicare”

(8) “you have”/“she has”/“he has”

(9) NH's SN

(10) State name

(*) indicates that the fill-in is manual

MARR13 MEDICARE DISALLOWANCE - MARRIAGE

To qualify for Medicare as a  (1)  ,  (2)  must meet one of these requirements:

 (3)  and  (4)  must  (5)  married under the laws of  (6)  , where  (7)  lived when  (8)  , or

 (9)  went through a ceremony which  (10)  thought resulted in a legal marriage with  (11)  and  (12)  still living with  (13)  when  (14)  , or

 (15)  the same rights as a spouse to inherit from  (16)  under the laws of  (17)  .

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

Fill-ins:

(1) “widow”/“widower”/“wife”/“husband”

(2) “you”/“she”/“he”

(3) “you”/“she”/ “he”

(4) NH's FN

(5) “have been”/“be”

(6) State name *

(7) NH's SN

(8) “she died”/”he died”/”she applied for Medicare”/”he applied for Medicare”/”you applied for Medicare”

(9) “you”/“she”/“he”

(10) “you”/“she”/“he”

(11) NH's SN

(12) “you were”/ “she was”/ “he was”

(13) “her”/“him”

(14) “she died”/”he died”/ “she applied”/ “he applied”/ “you applied”

(15) “you have”/“she has”/“he has”

(16) NH's SN

(17) State name *

(*) indicates that the fill-in is manual

MAR014

 (1)  not qualify for Medicare as  (2)   (3)  because  (4)  earlier marriage was never ended.

Fill-ins:

(1) “You do”/ “He does”/ “She does”

(2) NH Name (possessive)

(3) “widow”/ “widower”

(4) “your”/“his”/ “her”

MARD24 Dictated Text

MAR024 Disallowed Mother/Father - Claimant has Re-married

To qualify for  (1)  benefits,  (2)  must:

not be married now, or

be married to someone who is entitled to Social Security benefits.

 (3)  not qualify because  (4)  married a person who was not entitled to Social Security benefits, and  (5)  marriage has not ended.

Fill-ins:

(1) “mother's”/“father's”

(2) “you”/beneficiary's SN

(3) “You do”/“She does”/ “He does”

(4) “you”/“she”/“he”

(5) “your”/“her”/“his”

MAR026 Disallowed Spouse – Claimant has Re-married

 (1)  not qualify for benefits as a divorced  (2)  because  (3)  remarried and that marriage has not ended.

Fill-ins:

(1) “You do”/beneficiary's SN plus “does”

(2) “wife”/“husband”

(3) “you”/“she”/“he”

NL 00725.310 “MHP” UTIs – Medicare Health Plan

MHPC02 Caption

Information About  (1)  Health Plan Premiums

Fill-in:

(1) BGN plus BLN possessive/“Your”

MHP015 Award, Claimant Already Enrolled in Medicare Part C or D on another Account

Each month, we will continue to deduct  (1)  for  (2)  health plan premiums.

Fill-ins:

(1) Show the SUM of DAH-AMOUNT associated with DAH-ITEM 445 plus DAH-AMOUNT associated with DAH-ITEM 455 in the format $$$$$.CC

(2) BGN plus BLN (possessive)/ “your”

MHP043 Deduction for Medicare Part D

Each month, we will continue to deduct  (1)  for  (2)  Medicare prescription drug plan costs.

Fill-ins:

(1) PART D premium amount

(2) beneficiary's given name and last name, possessive/“your”

MHP044 Deduction for Medicare Part C and Part D

Each month, we will continue to deduct  (1)  for  (2)  health plan premiums and  (3)  for  (4)  Medicare prescription drug plan costs.

Fill-ins:

(1) PART C premium amount

(2) beneficiary's given name and last name, possessive/“your”

(3) PART D premium amount

(4) “her”/“his”/“your”

MHP053 Information about the Medicare Prescription Drug Plan (Part D)

Now that  (1)   (2)  eligible for Medicare,  (3)  can enroll in a Medicare prescription drug plan (Part D).

To learn more about the Medicare prescription drug plans and when  (4)  can enroll, visit  (5)  or call 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048). Medicare also can tell  (6)  about agencies in  (7)  area that can help  (8)  choose  (9)  prescription drug coverage.

If  (10)  limited income and resources, we encourage  (11)  to apply for the extra help that is available to assist with Medicare prescription drug costs. The extra help can pay the monthly premiums, annual deductibles and prescription co-payments. To learn more or apply, please visit  (12)  , call 1-800-772-1213 (TTY 1-800-325-0778) or visit the nearest Social Security office.

Fill-ins:

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

(2) “are”/“is”

(3) “she”/“he”/“you”

(4) “she”/“he”/“you”

(5) “http://www.medicare.gov

(6) “her”/ “him”/ “you”

(7) “her”/“his”/ “your”

(8) “her”/“him”/ “you”

(9) “her”/”his”/”your”

(10) “she has”/“he has”/ “you have”

(11) “her”/“him”/ “you”

(12) “www.socialsecurity.gov

NL 00725.315 “MIS” UTIs – Miscellaneous

MIS001 Abatement, Improper Applicant

We cannot process the application you filed for Social Security benefits on behalf of  (1)  because you are not the proper person to apply for benefits on  (2)  behalf.

Fill-ins:

(1) FN

(2) SN

MISR02 Misinformation Found, Earlier Filing Date

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

 (6)  did not file for benefits before  (7)  because we misinformed  (8)  about  (9)  eligibility for these benefits, and

 (10)  did not get benefits  (11)  could have.

We looked at the facts and found that we did misinform  (12)  . Therefore,  (13)  correct filing date is  (14)  . The beginning date for  (15)  benefits is based on this date.  (16) 

Fill-ins:

(1) “for” plus claimant's FN, otherwise NULL

(2) DOF in format “April 26, 1993”

(3) “you/the person who acted for you/the person who acted for, plus claimant's FN”

(4) Date in format “April 26, 1993” *

(5) Claimant's FN or “you”

(6) same as fill-in 3

(7) DOF in format “April 26, 1993”

(8) “you”/“her”/“him”

(9) FN possessive in format “Jack Jones” or last name possessive in format “Mr. Jones” or given name possessive in format “Jack's” or “your”

(10) “you”/“she”/“he”

(11) “you”/ “she”/ “he”

(12) same as fill-in 3

(13) same as fill-in 9

(14) Date of deemed filing in format “April 26, 1993” *

(15) “your”/“her”/“his”

(16) If fill-in 14 does not equal fill-in 4, then, “This is the earliest date, after we gave misinformation, that all requirements for these benefits were met.” Otherwise, NULL

(*) indicates that the fill-in is manual

MISR03 Misinformation Alleged, Earlier Filing Date Possible

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

 (6)  did not file for benefits before  (7)  because we misinformed  (8)  about  (9)  eligibility for these benefits, and

 (10)  did not get benefits  (11)  could have.

Fill-ins:

(1) “for” plus claimant's FN, otherwise NULL

(2) DOF in format “April 26, 1993”

(3) “you/the person who acted for you/the person who acted for, plus claimant's full name”

(4) Date of alleged misinformation in format “April 26, 1993” *

(5) Claimant's FN or “you”

(6) same as fill-in 3

(7) DOF in format “April 26, 1993”

(8) “you”/“her”/“him”

(9) FN possessive in format “Jack Jones'” or given name possessive in format “Jack's” or “Mr. Jones'” or “your”

(10) “you”/“she”/“he”

(11) “you”/ “she”/ “he”

(*) indicates that the fill-in is manual

MISR04 Misinformation Alleged Prior to January 1, 1983

You filed an application for benefits  (1)  on  (2)  . We can give  (3)  an earlier filing date if:

 (4)  did not file for these benefits before  (5)  because we misinformed  (6)  about  (7)  eligibility for these benefits, and

 (8)  did not get benefits  (9)  could have.

You said  (10)  did not file earlier because we gave misinformation on  (11)  . The law allows us to give  (12)  an earlier filing date if we misinformed  (13)  on or after January 1, 1983. Since you said we gave the misinformation before January 1, 1983, we are sorry but we cannot give  (14)  an earlier filing date.

Fill-ins:

(1) “for plus claimant's FN” or NULL

(2) DOF in format “April 26, 1993”

(3) Claimant's FN or “you”

(4) “you/the person who acted for you/the person who acted for, plus claimant's FN”

(5) DOF in format “April 26, 1993” *

(6) “you”/ “her”/ “him”

(7) Claimant's FN or “your”

(8) “you”/ “she”/ “he”

(9) “you”/ “she”/ “he”

(10) same as fill-in 4

(11) Date of alleged misinformation in format “April 26, 1993” *

(12) Claimant's FN or “you”

(13) “you”/ “her”/ “him”

(14) “you”/”her”/”him”

(*) indicates that the fill-in is manual

MISR05 Will Notify When Decision Made

We are looking into this and will let you know what we decide.

MISR06 Misinformation Alleged; Prior Filing Date Denied

We looked at the facts and found that we did not misinform  (1)  about  (2)  eligibility for these benefits. Therefore, we are sorry but  (3)  cannot get an earlier filing date.

Fill-ins:

(1) “you/the person who acted for you/the person who acted for, plus claimant's FN”

(2) Claimant's FN or “your”

(3) Claimant's FN possessive in format “Jack Jones” or “Mr. Jones” or “Jack's” or “you”

MISR07 To Applicant (Not Claimant) When Claimant Dies in or Before First MOE or During DIB Waiting Period

We are writing to tell you that we are not processing the application for Social Security benefits for  (1)  . This is because  (2)  could not have been entitled to benefits for any month before  (3)  death on  (4)  .

Fill-ins:

(1) FN

(2) “she/he”

(3) “her”/“his”

(4) month and year *

(*) indicates that the fill-in is manual

NL 00725.320 “MOE” UTIs – Month of Entitlement

MOE001 Conditional Month of Entitlement

When  (1)  applied for benefits, you asked that they start in the earliest possible month based on your work. We will need to know how much  (2)  will actually earn in  (3)  before we can decide if  (4)  is the earliest possible month.

Fill-ins:

(1) Ms. plus BLN/ Mr. plus BLN/you

(2) “she”/ “he”/“you”

(3) Year of entitlement in the format YYYY

(4) Year of entitlement in the format YYYY

MOE002 Conditional MOE (Used Only with MOE001)

For this reason, we will contact you after you report  (1)  earnings for the year. We will let you know if  (2)  first month of entitlement to benefits will be changed.

Fill-ins:

(1) “your”/“her”/“his”

(2) “your”/“her”/“his”

NL 00725.325 “MPD” UTIs – Income Related Monthly Reduction Amount

MPDC19 Medicare Part D - Caption

Medicare Prescription Drug Plan Enrollment

MPDC31 IRMAA D - Caption

Information About The Prescription Drug Coverage Income Related Monthly Adjustment Amount

MPD348 IRMAA D Deducted from CMA

We deducted  (1)  for  (2)  prescription drug coverage income-related monthly adjustment amount from the check  (3)  will receive for  (4)  on or about  (5)  .

(1) Money amount

(2) BGN plus BLN, possessive/”your”

(3) “she”/“he”/“you”

(4) COM in format July 2013

(5) date in format January 3, 2013

MPD349 IRMAA D Deducted from MBP

The monthly deduction for  (1)  prescription drug coverage income-related monthly adjustment amount is  (2)  .

(1) BGN plus BLN, possessive/'your”

(2) Money amount

NL 00725.330 “MSV” UTIs – Military Service

MSVC01 Military Service - Caption

Information About Military Service

MSV001 Military Service Not Usable, Other Federal Benefit

When we made our decision about  (1)  claim, we did not use  (2)  active military service for  (3)   (4)   (5)  . This is because another federal benefit is paid based on the same period of service. We cannot use active military service if another federal agency has used it to pay  (6)  a benefit.

Fill-ins:

(1) “your”/SN possessive/FN possessive

(2) “your”/NH SN possessive

(3) month and year

(4) “through”/null

(5) month and year/null

(6) “your”/NH SN

MSVR02 Military Service Not Usable, Less than 90 Days Service

When we made our decision about  (1)  claim we did not use  (2)  active military service for  (3)  . This is because  (4)  did not have at least 90 days of active service.

Fill-ins:

(1) “your”/SN possessive

(2) “your”/NH's SN possessive

(3) month/year through month/year *

(4) “you”/“she”/“he”

(*) indicates that the fill-in is manual

MSV005 Military Service Credits Before 1957 (Used Only with MSV004 or MSV010)

Please let us know if any other federal agency [except the Veteran's Administration] pays  (1)  a benefit based on this military service. Any other federal benefit  (2)   (3)  could affect the amount of  (4)  Social Security benefit.

Fill-ins:

(1) “you”/FN

(2) “you”/“she”/“he”

(3) “receive”/“receives”

(4) “your”/“her”/“his”

MSVR06 Military Service Unproven (Part or All)

We are checking to see if  (1)  active military service for  (2)  can be used in figuring the amount of  (3)  Social Security benefits. We will get in touch with you once we know if we can use this period of military service.

Fill-ins:

(1) “your”/NH's FN

(2) month/year; month/year and month/year; month/year through month/year *

(3) “your”/beneficiary's SN possessive

(*) indicates that the fill-in is manual

MSVR07 Military Service Not Used Due to Type of Discharge

When we made our decision about  (1)  claim, we did not use  (2)  active military service for  (3)  . We cannot use this service because of the type of discharge  (4)   (5)  .

Fill-ins:

(1) “your”/SN possessive/FN possessive

(2) “your”/NH's FN possessive

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

(4) “you”/NH's FN

(5) “have”/“has”

(*) indicates that the fill-in is manual

MSV010 Military Service Used

In addition to  (1)  earnings, we used  (2)  active military service to figure the amount of  (3)  Social Security benefits.

Fill-ins:

(1) “your”/NH FN possessive

(2) “your”/“her”/“his”

(3) “your”/SN possessive

NL 00725.340 “ONS” UTIs – Disability Onset Paragraphs

ONS001 Onset Different From Alleged

The date we found  (1)  disabled is different from the date  (2)  gave us on the application.

Fill-in:

(1) FN/”you”

(2) “you”/“he”/ “she”

ONS002 Later Onset Established because Earnings Requirement Not Met until Later

 (1)  may have been disabled before this date  (2)  . However,  (3)  did not meet the disability earnings requirement until  (4)  . We explain this requirement in the enclosed pamphlet, called “How You Earn Credits.” (Pub #05-10072)

Fill-ins:

(1) null + FN/”She”/ “He”/ “You”

(2) onset date in the format “July 17, 2012”

(3) “she”/“he”/ “you”

(4) onset date in the format “July 17, 2012”

ONS003 Onset Date

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

Fill-ins:

(1) FN/“you”

(2) onset date in the format “July 17, 2012”

NL 00725.345 “PAY” UTIs – Payment

PAYC01 Caption

What We Will Pay And When

PAYC02 Caption

 (1)  Payment of $  (2) 

Fill-ins:

(1) “Your”/SN possessive

(2) Amount of payment

PAYC03 Caption

 (1)  Regular Monthly Payment

Fill-in:

(1) “Your”/SN possessive

PAYC04 Caption

 (1)  Payment of $  (2) 

Fill-ins:

(1) “Your”/SN possessive

(2) Amount of first payment

PAYC12 Caption

Why We Cannot Pay Current Benefits

PAYC15 Caption

Why We Cannot Pay Past Benefits

PAYR01 Partial Award

We used  (1)   (2)  to decide how much to pay  (3)  . We are still working on  (4)  claim. When we make a final decision about the  (5)  , we will figure the amount of  (6)  payments. We will send  (7)  another letter to let  (8)  know if there will be any change in  (9)  payments.

Fill-ins:

(1) “your”/Beneficiary's FN possessive

(2) dictated text *

(3) “you”/“her”/“him”

(4) “your”/“her”/“his”

(5) dictated text *

(6) “your”/“her”/“his”

(7) “you”/“her”/“him”

(8) “you”/“her”/“him”

(9) “your”/“her”/“his”

(*) indicates that the fill-in is manual

PAY002 PMA or CMA Different From Ongoing Amount

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

Fill-ins:

(1) Amount of first payment

(2) Month, day and year of expected receipt

PAY003 Payment Months (Concluding Sentence for PAY002)

This is the  (1)  money  (2)   (3)  due for  (4)   (5)   (6)  .

Fill-ins:

(1) null

(2) “you”/SN/FN/First Name

(3) “are”/“is”

(4) month and year

(5) “and”/“through”/null

(6) month and year/null

PAY004 Current or Deferred Benefits Due

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

Fill-ins:

(1) Payment amount

(2) Month and year payment is due

(3) Month, day and year of expected receipt

PAY006 Medical Insurance Premium Deduction

The above amounts may change because of medical insurance premium deductions.

PAY009 Ongoing Benefit Amount

 (1)  After that you will receive $  (2)   (3)   (4)   (5)  .

Fill-ins:

(1) null/”You will receive”

[1a] for [1b].

[1a] Money fill-in

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

(2) Money fill-in

(3) “on or about the”/“for”/“through”

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

(5) “of each month”/null

PAY012 Payment Through Direct Deposit

 (1)  and any future payments will go to the financial institution you selected. Please let us know if you change your mailing address, so we can send you letters directly.

Fill-in:

(1) “These”/“This”

PAY013 Monthly Credited Amount Less than One Dollar

 (1)  monthly benefits are less than a dollar. So, we will not pay you a check each month. We will hold the monthly benefits  (2)  due and pay you this money at the end of the year.

Fill-ins:

(1) “Your”/SN possessive/FN possessive/First Name possessive

(2) “you are”/“she is”/“he is”

PAY018 Summary Sheet Included

Later in this letter, we will show you how we figured  (1)   (2)  .

Fill-ins:

(1) null

(2) “this amount”/“these amounts”

PAY019 Summary Sheet - Introduction

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

Fill-ins:

(1) “your”/FN possessive

(2) “first payment”

(3) null

PAY020 Summary Sheet – Benefits Due

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

Fill-ins:

(1) month and year

(2) null/“,”

PAY022 Summary Sheet – Subtraction Explanation

 (1)  we subtracted because  (2) 

Fill-ins;

(1) “Amount”/“Amounts”

(2) “of:”/“of”

PAY023 Summary Sheet - Introduction

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

Fill-ins:

(1) FN possessive/“your”

(2) “regular monthly payment”

(3) Month and year

PAY024 Summary Sheet – Monthly Benefit Amount

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

Fill-ins:

(1) “you are”/“she is”/“he is”

(2) null/variable length ellipsis

(3) MBA amount

PAY025 Summary Sheet – Monthly Payment Amount

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

Fill-ins:

(1) SN possessive/“your”

(2) “first payment”

(3) variable length ellipsis

(4) Money amount

PAY026 Summary Sheet - Introduction

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

Fill-ins:

(1) FN possessive/“your”

(2) “current”/“past”

PAYC27 Caption

How  (1)  Benefits Can Be Paid

Fill-in:

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

PAY027 Summary Sheet – Subtraction Explanation

 (1)  we must subtract because  (2)  .

Fill-ins:

(1) “Amount”/“Amounts”

(2) “of”/“of:”

PAY028 Summary Sheet – Conditional Award Total

This equals . . . . . . . . . . . . . . .$00.00

PAY030 Combined Check

 (1)  benefit is $  (2)  on  (3)  earnings record and $  (4)  as a  (5)  .

Fill-ins:

(1) “your”/ “her”/ “his”

(2) Money fill-in

(3) “your”/ “her”/ “his”

(4) Money fill-in

(5) Type of benefit

PAY032 Auxiliary/Survivor Awarded after Primary

 (1)  benefit is $  (2)  as a  (3)  . This is in addition to the benefit of $  (4)  on  (5)  own earnings record.

Fill-ins:

(1) “your”/ “her”/ “his”

(2) Money fill-in

(3) Type of benefit

(4) Money fill-in

(5) “your”/ “her”/ “his”

PAY033 Technical Entitlement – PMA Only Due in Addition to Regular Payment

 (1)  will also receive a payment of $  (2)  for  (3)  . This is the only money  (4)  due on claim number  (5)  .

Fill-ins:

(1) “you”/ “she”/ “he”

(2) Money fill-in

(3) Date fill-in

(4) “you are”/ “she is”/ “he is”

(5) DE other account SSN

PAY041 Summary Sheet – SMI Arrearage

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

Fill-in:

(1) Premium amount

PAY042 Summary Sheet – Benefits Due

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

Fill-ins:

(1) Month and year

(2) null or variable length ellipsis

(3) Amount

PAY043 Payment Months (Concluding Sentence for PAY002, Two Periods of Payment)

This is the  (1)  money  (2)  due for  (3)   (4)   (5)  and  (6)   (7)   (8)  .

Fill-ins:

(1) null

(2) “you are”/ “she is”/ “he is”

(3) Month and year

(4) “and”/“through”/null

(5) Month and year/null

(6) Month and year

(7) “and”/“through”/null

(8) Month and year/null

PAY044 Payment Months (Concluding Sentence for PAY002, Three Periods of Payment)

This is the  (1)  money  (2)  due for  (3)   (4)   (5)  ,  (6)   (7)   (8)  and  (9)   (10)   (11)  .

Fill-ins:

(1) null

(2) “you are”/“she is”/“he is”

(3) Month and year

(4) “and”/“through”/null

(5) Month and year/null

(6) Month and year

(7) “and”/“through”/null

(8) Month and year/null

(9) Month and year

(10) “and”/“through”/null

(11) Month and year/null

PAY045 Payment Months (Concluding Sentence for PAY002, Four Periods of Payment)

This is the  (1)  money  (2)  due for  (3)   (4)   (5)  ,  (6)   (7)   (8)  ,  (9)   (10)   (11)  and  (12)   (13)   (14)  .

Fill-ins:

(1) null

(2) “you are”/“she is”/“he is”

(3) Month and year

(4) “and”/“through”/null

(5) Month and year/null

(6) Month and year

(7) “and”/“through”/null

(8) Month and year/null

(9) Month and year

(10) “and”/“through”/null

(11) Month and year/null

(12) Month and year

(13) “and”/“through”/null

(14) Month and year/null

PAY046 Summary Sheet – Work Deductions (Use with PAY022)

 (1)  work  (2)   (3) 

Fill-ins:

(1) NH FN possessive/“Your”

(2) null/variable length ellipsis

(3) Amount

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

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

Fill-ins:

(1) FN possessive/“your”

(2) Amount

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

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

Fill-in:

(1) Amount of premiums

PAY049 Summary Sheet - Subtotal

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

Fill-in:

(1) Amount

PAY050 Summary Sheet - Rounding

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

Fill-in:

(1) Rounding amount

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

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

Fill-ins:

(1) FN possessive/“your”

(2) Variable length ellipsis/null

(3) Attorney fee withholding amount

PAY052 Summary Sheet – Alien Tax Withholding (Use with PAY022)

U.S. Federal taxes due on  (1)  Social Security  (2)   (3) 

Fill-in:

(1) FN possessive/“your”

(2) null/variable length ellipsis

(3) Amount of tax withheld

PAY053 Summary Sheet – Total Subtractions (Use with PAY022)

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

Fill-in:

(1) Amount

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

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

Fill-ins:

(1) FN possessive/“your”

(2) Amount

PAY055 Summary Sheet – Prisoner Suspension (Use with PAY027)

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

Fill-ins:

(1) FN possessive/“your”

(2) Amount withheld

PAY056 Summary Sheet – Work Deduction (Use with PAY027)

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

Fill-ins:

(1) FN possessive/“your”

(2) Amount deducted

PAY057 Summary Sheet – Medical Insurance (Use with PAY027)

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

Fill-in:

(1) Premium amount withheld

PAY058 Summary Sheet (Use with PAY020)

 (1)   (2)   (3) 

Fill-ins:

(1) “and”/“through”

(2) Month and year

(3) “,”/null

PAY059 Summary Sheet (Use with PAY020)

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

Fill-ins:

(1) “and”/null

(2) “,”/null

PAY060 Summary Sheet (Use with PAY020)

considering work and earnings through  (1) 

Fill-in:

(1) Year

PAY061 Summary Sheet (Use with PAY042)

 (1)   (2)   (3)   (4) 

Fill-ins:

(1) “and”/“through”

(2) Month and year

(3) null/variable length ellipsis

(4) Amount/null

PAY062 Summary Sheet (Use with PAY042)

with premiums for medical insurance deducted $  (1) 

Fill-in:

(1) Amount

PAY063 Summary Sheet

less monthly rounding of benefits $  (1) 

Fill-in:

(1) Amount

PAY064 Summary Sheet

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

Fill-ins:

(1) Month and year (COM)

(2) null/variable length ellipsis

(3) Amount

PAY065 Summary Sheet

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

Fill-in:

(1) Amount

PAY066 Summary Sheet

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

Fill-in:

(1) Amount

PAY067 Payment Prior to Completion of Claim/PMA Exists

We will subtract $  (1)  from your next check. This is the amount we paid you before we finished work on  (2)  claim.

Fill-ins:

(1) CPA in format $$,$$$.¢¢

(2) “your”/FN (Possessive)

PAY068 Payment Prior to Completion of Claim/Equal to PMA

When we figured how much to pay you through  (1)  , we subtracted the money which we already paid you while we finished work on  (2)  claim.

Fill-ins:

(1) If LAF equals C: CMA minus one month in format January 1993. If LAF does not equal C: find first EFD with equal RFD to current LAF and is greater than DOEC. This fill-in is EFD minus one month in format January 1993.

(2) “your”/FN (Possessive)

PAY069 Summary Sheet

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

Fill-in:

(1) CPA in format $$,$$$.¢¢

PAY072 Regular Monthly Payment When DAA/Installment Present

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

Fill-ins:

(1) “your”/“her”/“his”

(2) Money amount in format $$$.¢¢

(3) Month/year

PAY073 DAA Past Due Benefits and Installment

 (1)  still due back payments of $  (2)  for past months.  (3)  will receive this money over a period of months. We will send  (4)  $  (5)  more each month with  (6)  regular payment until all of the extra money is paid.

Fill-ins:

(1) “you are”/“she is”/“he is”

(2) Amount of past due benefit payable

(3) “you”/“she”/“he”

(4) “you”/“her”/“him”

(5) Amount of installment payment

(6) “your”/“her”/“his”

PAY074 Voluntary Tax Amount Withheld

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

Fill-in:

(1) Amount withheld for voluntary Federal tax withholding

PAY088 Payment Cycling

 (1)  next payment of $  (2)  , which is for  (3)  , will be received on or about the  (4)  of  (5)  .

Fill-ins:

(1) “Your”/beneficiary's FN possessive

(2) MBP in the format “$$$$$.¢¢”

(3) COM in the format “June 1998”

(4) third/second Wednesday/third Wednesday/fourth Wednesday

(5) COM + 1, in the format “June 1998”

PAY090 Summary Sheet (DE) Amount of Benefit on Other SSN

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

Fill-ins:

(1) “you are”/“she is”/ “he is”

(2) Variable length ellipsis

(3) Money Fill-in

PAY161 LAF is C but the CMA is $0.00

No Payment is due at this time because of adjustments made to  (1)  benefits.

Fill-in:

(1) “her”/“his”/“your”

NL 00725.350 “PMT” UTIs – Payment Cycling

PMT001 Payment Cycling – How Cycle is Established

The day of the month you receive  (1)  payments depends on  (2)  date of birth.

Fill-in:

(1) “your”/null plus FN possessive

(2) “your”/“his”/“her”

PMT002 Payment Cycling – Payment Date Change

Because  (1)  now entitled to benefits on a different Social Security record, the day you will receive  (2)  payment has changed.

Fill-ins:

(1) “you are”/Beneficiary's FN plus “is”/beneficiary's First Name plus “is”

(2) “your”/“her”/“his”

NL 00725.355 “PRI” UTIs – Prisoner Provisions

PRI011 DIB — Beneficiary Imprisoned Before 2/95

We may be able to pay  (1)  up to February 1995 if  (2)  in a rehabilitation program while  (3)  imprisoned. Two things must be true about the program:

It must be approved for  (4)  by a court, and

It must be designed to make it possible for  (5)  to work after  (6)  release.

Fill-ins:

(1) “you”/Beneficiary's FN

(2) “you were”/“she was”/“he was”

(3) “you were”/“she was”/“he was”

(4) “you”/“her”/“him”

(5) “you”/“her”/“him”

(6) “your”/“her”/“his”

PRI014 Beneficiary Imprisoned 2/95 through 3/31/2000

We cannot pay  (1)  because  (2)  imprisoned for the conviction of a crime that can carry a sentence of more than one year. We cannot pay  (3)  even if  (4)  actual sentence is shorter.

Fill-ins:

(1) “you”/Beneficiary's FN

(2) “you are”/“she is”/ “he is”

(3) “you”/“her”/“him”

(4) “your”/“her”/”his”

PRI015 Beneficiary Imprisoned Before 2/95

We cannot pay  (1)  because  (2)  imprisoned before February 1995 for the conviction of a crime considered to be a felony. Beginning February 1995, the law changed. Now, we cannot pay Social Security benefits if  (3)  imprisoned for conviction of a crime that can carry a sentence of more than one year. We cannot pay  (4)  benefits even if  (5)  actual sentence is shorter.

Fill-ins:

(1) “you”/Beneficiary's FN

(2) “you were”/“she was”/“he was”

(3) “you are”/“she is”/ “he is”

(4) “you”/“her”/“him”

(5) “your”/“her”/“his”

PRI016 Number Holder Imprisoned – Entitled Auxiliaries Can be Paid

Even though we cannot pay  (1)  , we can pay other members of  (2)  family if they are entitled on  (3)  record.

Fill-ins:

(1) “you”/Beneficiary's FN

(2) “your”/“her”/“his”

(3) “your”/“her”/“his”

PRI017 Benefits Payable after Release from Prison

We may be able to pay  (1)  when  (2)  released. Please get in touch with us after  (3)  released. Then we will review your case to see if we can pay  (4)  .

Fill-ins:

(1) “you”/Beneficiary's FN

(2) “you are”/“she is”/“he is”

(3) “you are”/“she is”/“he is”

(4) “you”/“her”/“him”

PRI021 Suspending Benefits to a Sexually Dangerous Person

We cannot pay  (1)  because:

 (2)  convicted of a crime and confined in a jail or prison;

The crime included sexual activity, and

when  (3)  completed  (4)  sentence,  (5)  immediately sent by court order to an institution at public expense.

The court decided  (6)  a sexually dangerous person.

Fill-ins:

(1) Ms plus BLN/Mr plus BLN/BGN/BGN plus BLN/”you”

(2) “she was”/“he was”/“you were”

(3) “she”/“he”/“you”

(4) “her”/“his”/“your”

(5) “she was”/“he was”/“you were”

(6) “she was”/“he was”/“you were̶