Identification Number:
NL 00725 TN 24
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. 24, 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 00725.365 to NL 00725.490 are all new sections.

NL 00725.365 “RDE” UTIs - Rate Decrease

NL 00725.370 “REC” UTIs - Reconsideration Decision

NL 00725.375 “REF” UTIs - Referral

NL 00725.380 “REL” UTIs - Family Relationship

NL 00725.390 “REP” UTIs - Attorney Representation

NL 00725.395 “RIN” UTIs - Rate Increase

NL 00725.400 “RPY” UTIs - Representative Payee

NL 00725.405 “RRB” UTIs - Railroad Retirement Board

NL 00725.410 “RSD” UTIs - Residence

NL 00725.415 “SEI” UTIs - Self-Employment Income

NL 00725.420 “SSA” UTIs - Headings and Signatures

NL 00725.425 “STU” UTIs - Student Status

NL 00725.430 “SUS” UTIs - Suspensions deleted (for other than work)

NL 00725.435 “TAX” UTIs - Taxation of Benefits

NL 00725.440 “TER” UTIs - Terminations

NL 00725.445 “TOT” UTIs - Totalization

NL 00725.450 “TWP” UTIs - Trial Work Period

NL 00725.460 “VRN” UTIs - Vocational Rehabilitation

NL 00725.465 “VTW” UTIs - Voluntary Tax Withholding

NL 00725.470 “WCP” UTIs - Workers' Compensation

NL 00725.475 “WDS” UTIs - Withdrawal

NL 00725.480 “WDW” UTIs - Work & Earnings facility of payment

NL 00725.485 “WEP” UTIs - Windfall Elimination Provision

NL 00725.490 “WFO” UTIs - Windfall Offset

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NL 00725.365 “RDE” UTIs – Rate Decrease

RDE001 Withholding – Maritime Service

We have withheld from  (1)  first check unpaid Social Security taxes of  (2)  for maritime services.

Fill-ins:

(1) “your”/“her”/“his”

(2) Amount in format “$99,999.99”

RDE002 Reduced Benefits – Other Entitlement

We reduced  (1)  monthly benefit amount beginning  (2)  because we started paying another person on this record.

Fill-ins:

(1) FN possessive/“your”

(2) Date in format “August 1991”

NL 00725.370 “REC” UTIs – Reconsideration Decision

REC005 English Translation for Spanish Cover Letter – Affirmation of Denial on Reconsideration – Domestic/Foreign Address

The enclosed English version of the “Determination of Reconsideration” explains why your claim cannot be approved. If you need help with the translation, ask someone who understands both English and Spanish to help you. Or contact any Social Security office.

REC006 English Translation for Spanish Cover Letter – Affirmation of Denial on Reconsideration – Mexico Address

The enclosed English version of the “Determination of Reconsideration” explains why your claim cannot be approved. If you need help with the translation, ask someone familiar with both languages to help you, or contact any Social Security office or the nearest U.S. Embassy or Consulate.

NL 00725.375 “REF” UTIs – Referral

REFC01 Caption

If You Have Any Questions

REF001 Referral – Domestic Address

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

 (2) 

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

Fill-ins:

(1) null

(2) Field office address

REF002 Referral – Foreign Address

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

 (2) 

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

Fill-ins:

(1) null

(2) “any Social Security office”/“the Veterans Affairs Regional Office, Social Security Division, 1131 Roxas Boulevard, Manila”/“any Social Security office or the nearest United States Embassy or consulate”/“any Social Security office or the nearest United States Embassy or consulate. Or, if you live in the Philippines, you may contact the Veterans Administration Regional Office, Social Security Division, 1131 Roxas Boulevard, Manila/the nearest United States Embassy or consulate”

REF003 Referral – Domestic Address

We invite you to visit our website at www.ssa.gov on the Internet to find general information about Social Security. If you have any specific questions, you may call us toll free at 1-800-772-1213, or call your local Social Security office at  (1)  .

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

 (2) 

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

Fill-ins:

Local field office telephone number in the format 1-XXX-XXX-XXXX

Field Office Address

REF008 Field Office Referral - Default

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

Fill-in:

(1) null

REF011 Referral (Award Notice Only) 10 Digit Title II Public Contact Number other than National Number) and LAF = E

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

 (2) 

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

If you have any questions about railroad annuities or about your monthly check, please contact your local Railroad District office or the Railroad Retirement Board.

The address is:

U.S. Railroad Retirement Board

844 Rush Street

Chicago, Illinois 60611-2092

Fill-ins:

(1) Local DO telephone number on TRIDE in format 1-xxx-xxx-xxxx

(2) Street address, City, State and Zip Code corresponding to DOC

REF012 Referral (Award Notice Only) - Default

If you have any questions about your Social Security benefits, call us toll free at 1-800-772-1213. We can answer most questions over the phone. You can also write or visit any Social Security Administration office. If you prefer to visit one of our offices, call the 800 number and we can give you the local office address and telephone number.

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

If you have any questions about railroad annuities or about your monthly check, please contact your local Railroad District office or the Railroad Retirement Board.

The address is:

U.S. Railroad Retirement Board

844 Rush Street

Chicago, Illinois 60611-2092

REF013 Referral Without Field Office Phone Number (Award Notice Only)

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

 (1) 

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

If you have any questions about railroad annuities or about your monthly check, please contact your local Railroad District office or the Railroad Retirement Board.

The address is:

U.S. Railroad Retirement Board

844 Rush Street

Chicago, Illinois 60611-2092

Fill-in:

(1)

REF050 English Translation for Spanish Cover Letter – Awards – Domestic/Foreign Address

The attached sheet explains your right to question the decision on your claim. If you have any questions, contact any Social Security office. Most of your questions can be answered by telephone or mail. If you visit an office, please have this notice with you.

NL 00725.380 “REL” UTIs – Family Relationship

RELD01 Dictated Text

RELD02 Dictated Text

REL002 Disallowance – Divorced Claimant not Married 10 Years

 (1)  not qualify for benefits as a divorced  (2)  because  (3)  not married to  (4)  for at least 10 years in a row.

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

Fill-ins:

(1) “You do”/“She does”/“He does”

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

(3) “you were”/“she was”/“he was”

(4) NH FN

REL004 Disallowance – Child's Relationship Not Proven

 (1)  not qualify for benefits because the facts we have do not show that  (2)   (3)  child.

Fill-ins:

(1) “You do”/“She does”/“He does”

(2) “you are”/“she is”/ “he is”

(3) NH FN possessive

REL006 Disallowance – Adopted Child – Equitable Adoption Does not Apply

 (1)  not qualify for child's benefits on  (2)  Social Security record because the facts we have show that:

  •  (3)  not adopted by  (4)  , and

  •  (5)  not have the right to inherit from  (6)  as  (7)  child under the laws of  (8)  .

Fill-ins:

(1) “You do”/“She does”/ “He does”

(2) NH-name possessive

(3) “you were”/“she was”/“he was”

(4) “her”/“him”

(5) “You do”/“She does”/ “He does”

(6) “her”/“him”

(7) “her”/“his”

(8) State name

RELR07 Disallowance – Child not Adopted by Number Holder

 (1)  not qualify for benefits as an adopted child on  (2)  Social Security record because:

 (3)  not  (4)  natural child or stepchild, and

 (5)  not adopted by  (6)  through a court action in the United States.

Fill-ins:

(1) “You do”/“She does”/ “He does”

(2) NH-name possessive

(3) “you are”/“she is”/ “he is”

(4) ““her”/“his””

(5) “you were”/“she was”/“he was”

(6) NH SN

REL009 Disallowance – Adoption by Number Holder's Surviving Spouse not within Time Limit

 (1)  not qualify for benefits as  (2)  child because:

 (3)  did not begin the adoption proceedings before  (4)  died, and

 (5)  did not complete the proceedings within 2 years of  (6)  death.

Fill-ins:

(1) “You do”/ “She does”/ “He does”

(2) NH-Name possessive

(3) SN of NH

(4) “she”/“he”

(5) Surviving spouse name

(6) “her”/“his”

REL010 Surviving Divorced Mother/Father Does not have Proper Relationship to Child

To quality for  (1)  benefits,  (2)  must meet one of these requirements:

 (3)  the natural  (4)  of  (5)  child, or

 (6)  adopted  (7)  child while  (8)  married to  (9)  , or

 (10)  adopted  (11)  child while  (12)  married to  (13)  , or

 (14)  and  (15)  adopted a child while married.

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

Fill-ins:

(1) “mother's”/“father's”

(2) “you”/“she”/“he”

(3) “you are”/“she is”/ “he is”

(4) “mother”/“father”

(5) NH FN possessive

(6) NH SN

(7) “your”/“her”/“his”

(8) ““she was”/ “he was”/ “you were””

(9) “her”/“him”

(10) “you”/“she”/“he”

(11) NH SN possessive

(12) “she was”/ “he was”/“you were”

(13) “her”/“him”

(14) “you”/“she”/ “he”

(15) NH SN

REL011 Stepparent Disallowance – Parent and Stepparent Divorced before Stepchild's First Possible Month of Entitlement

If  (1)  legally adopted  (2)  , contact us because  (3)  may qualify for benefits as an adopted child.

Fill-ins:

(1) NH full name

(2) “you”/beneficiary's full name

(3) “you”/“she”/“he”

REL012 Disallowance – Claimant is Stepchild – Requirement for Duration of Parents' Marriage not Met

 (1)  not qualify for child's benefits on  (2)  Social Security record because  (3)  and  (4)   (5)  were not married for at least  (6)  . Our records show that they were married on  (7)  and  (8)  on  (9)  .

Fill-ins:

(1) “You do”/“She does”/ “He does”

(2) NH-Name possessive

(3) Mr.plus NH-SURNAME/Ms. plus NH-SURNAME

(4) “mother”/“father”

(5)“9 months/“12 months before [6a] applied for benefits.”

[6a] “you”/“she”/ “he” Date NH married child's parent, in format, June 10, 1991 “(NH-SN) died”/“(8a) applied”

[8a] “you”/“she”/“he” NH's date of death or claimant application date, in format July 10, 1991

(6)

(7)

(8)

(9)

RELR13 Disallowance – Stepchild Claimant – Natural Parent and Stepparent Divorced before Application Filed

 (1)  not qualify for benefits on  (2)  Social Security record because  (3)  and  (4)   (5)  divorced before  (6)  .

Fill-ins:

(1) “You do”/“She does”/“He does”

(2) FN of NH possessive

(3) FN of NH

(4) “Your”/NOTICE-PIC-NAME

(5) “mother”/“father”

(6) “(NH surname) died”/“[6a] applied for benefits”

[6a] “you”/“she”/“he”

REL014 Disallowance – Stepchild, Grandchild or Step-grandchild

 (1)  not qualify for benefits because the facts we have do not show that  (2)   (3)  of  (4)  .

Fill-ins:

(1) “You do”/ “She does”/”He does” “

(2) “you are”/“she is”/ “he is”

(3) “the stepchild”/“the grandchild or step grandchild”

(4) NH-name

REL015 Disallowance – Parent not the Parent of the Number Holder

 (1)  not qualify for benefits because the facts we have do not show that  (2)   (3)   (4)  .

Fill-ins:

(1) “You do”/“She does”/ “He does”

(2) “you are”/“she is”/ “he is”

(3) NH-Name possessive

(4) “parent”/“stepparent”/“adoptive parent”

REL016 Disallowance – Adoptive Parent

 (1)  not qualify for parent's benefits on  (2)  Social Security record because  (3)  did not adopt  (4)  before  (5)  reached age 16. Our records show that  (6)  was born on  (7)  and that the adoption was final on  (8)  .

Fill-ins:

(1) “You do”/ “She does”/ “He does”

(2) NH-name possessive

(3) “you”/“she”/“he”

(4) “her”/“him”

(5) “she”/“he”

(6) “she”/“he”

(7) NH-DOB, in format June 6, 1969

(8) Date of adoption, in format April 5, 1989

REL017 Disallowance – Not a Parent

 (1)  not qualify for benefits as  (2)  parent because  (3)  did not marry  (4)   (5)  before  (6)  reached age 16. Our records show that  (7)  was born on  (8)  and that  (9)  married  (10)   (11)  on  (12)  .

Fill-ins:

(1) “You do”/“She does”/ “He does”

(2) NH-name possessive

(3) “you”/“she”/“he”

(4) “her”/“his”

(5) “mother”/“father”

(6) NH-name

(7) NH SN

(8) NH's DOB

(9) “you”/“she”/“he”

(10) “her”/“his”

(11) “mother”/“father”

(12) Marriage date in the format September 13, 1999

REL023 Disallowance – Claimant does not Meet Duration of Marriage Requirement or Alternative

 (1)  not qualify for benefits as  (2)   (3)  because:

 (4)  not married to  (5)  for at least  (6)   (7)  , or

 (8)  not the natural or adoptive parent of  (9)  child.

Fill-ins:

(1) “You do”/“She does”/ “He does”

(2) NH FN possessive

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

(4) “you were”/“she was”/“he was”

(5) “her”/“him”

(6) “9 months before”/“one year just before applying for benefits”

(7) “he died”/“she died”/null

(8) “you are”/“she is”/“he is”

(9) “her”/“his”

REL024 Disallowance - 216H2a or 216H3 Child –Relationship not Established (REL024 Replaces REL005)

 (1)  not qualify for child's benefits because the facts we have do not show that  (2)   (3)  child.

To qualify as a child, one of the following must be true:

The child has the right to inherit the worker's personal property as a natural child. This is based on the inheritance laws of the state where the worker and his or her home when he or she died or when the child's claim was filed, or

The worker stated in writing that the child is his or her son or daughter, or

A court ordered the worker to contribute to the child's support because the child is his or her son or daughter, or

A court found that the worker is the child's father or mother, or

There are other facts which show that the worker is the child's father or mother. And the worker was living with the child or was contributing to the child's support when the worker died or when the child's application was filed.

The facts we have show that none of these are true about  (4)  relationship to  (5)  .

Fill-ins:

(1) You do/She does/He does

(2) “you are”/“she is”/“he is”

(3) NH name (possessive)

(4) your/Beneficiaries name, possessive

(5) NH name

NL 00725.390 “REP” UTIs – Attorney Representation

REPC01 Attorney Representation - Caption

If You Want Help With Your Appeal

REP001 Attorney Representation

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

If you get someone to help you, you should let us know. If you hire someone, we must approve the fee before he or she can collect it. And if you hire a lawyer, we will withhold up to 25 percent of any past due benefits to pay toward the fee.

NL 00725.395 “RIN” UTIs – Rate Increase

RIN001 Benefit Increase – Beneficiary Terminated

We raised  (1)  monthly benefit amount beginning  (2)  because benefits to another entitled person stopped.

Fill-ins:

(1) SN possessive/“your”

(2) Month and year of increase, in format June 1991

RIN003 Benefit Increase – Due to Death

We raised  (1)  monthly benefit beginning  (2)  because of  (3)  death in  (4)  .

Fill-ins:

(1) SN possessive/“your”

(2) Month and year of increase in format “June 1991”

(3) Beneficiary's name possessive

(4) Date of death in format “June 1991”

RIN011 Increased Auxiliary Benefit because of Number Holder Increase

We changed  (1)  monthly benefit amount beginning  (2)   (3)  because we raised  (4)  benefit.

Fill-ins:

(1) “your”/“her”/“his”

(2) Earliest month of benefit increase, in format June 2008

(3) null/“and again in”

(4) Month YYYY/Month YYYY and Month YYYY/Month YYYY, Month YYYY and Month YYYY

(5) NH-name possessive

RIN016 COLA Increase(s) and Re-computation

We raised  (1)  monthly benefit amount beginning  (2)  because the cost of living increased. We also raised  (3)  monthly benefit in  (4)  to give  (5)  credit for  (6)   (7)  earnings. We use each year's earnings to raise benefits the following January.

Fill-ins:

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

(2) Month YYYY/Month YYYY and again beginning Month YYYY/Month YYYY, Month YYYY and Month YYYY/Month YYYY, Month YYYY, Month YYYY and Month YYYY/ Month YYYY, Month YYYY, Month YYYY, Month YYYY and Month YYYY

(3) “your”/“her”/“his”

(4) Date in format “January 1992/January 1992 and January 1993/January 1992, January 1993 and January 1994”

(5) “you/“her”/“his”

(6) “your”/“her”/“his”

(7) Show year preceding year in fill-in (4) in format “1991/1991 and 1992/1991, 1992 and 1993”

RIN017 COLA Increase and Re-computation - Auxiliary

We changed  (1)  monthly benefit amount beginning  (2)  because the cost of living increased. We also raised  (3)  benefit beginning  (4)  .

Fill-ins:

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

(2) Month YYYY/Month YYYY and again beginning Month YYYY/Month YYYY, Month YYYY and Month YYYY/Month YYYY, Month YYYY, Month YYYY and Month YYYY/Month YYYY, Month YYYY, Month YYYY, Month YYYY and Month YYYY

(3) “your”/“her”/“his”

(4) Month YYYY/Month YYYY and Month YYYY/Month YYYY, Month YYYY and Month YYYY/Month YYYY, Month YYYY, Month YYYY and Month YYYY

RIN020 Benefit Increased – Credit for Work Months

We raised  (1)  monthly benefit starting  (2)  . We gave  (3)  credit for months when  (4)  :

  • At least full retirement age, and

  • Did not receive a retirement benefit because of  (5)  work and earnings

Fill-ins:

(1) FN possessive /“your”

(2) date of increase in the format “June 1998”

(3) “you”/”him”/'her”

(4) “you were”/”he was”/”she was”

(5) “your”/“his”/“her”

RIN021 Benefit Increase – Incorrectly Paid

We raised  (1)  monthly benefit beginning  (2)  to give credit for benefits which we did not pay at the full rate before  (3)  reached  (4)   (5)   (6)   (7)   (8)  .

Fill-ins:

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

(2) date, in the format June 1998

(3) “you”/“she”/“he”

(4) age 62/full retirement age,

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

(6) “and”/null

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

(8) months/null

RIN054 Number Holder's Benefit Increased by Two or More Re-computations, but not More than 4

We again raised  (1)  monthly benefit beginning  (2)  to give

credit for  (3)   (4)  earnings.

Fill-ins:

(1) “your”/“her”/“his”

(2) Month YYYY/Month YYYY and Month YYYY/Month YYYY, Month YYYY and Month YYYY

(3) “your”/“her”/“his”

(4) YYYY/YYYY and YYYY/YYYY, YYYY and YYYY

RIN055 Number Holder's Benefit Increased by One Re-computation

We raised  (1)  monthly benefit amount beginning  (2)  to give  (3)  credit for  (4)   (5)  earnings. We use each year's earnings to raise benefits the following January.

Fill-ins:

(1) “your”/“her”/“his”

(2) earliest PIA increase in the format “Month YYYY”

(3) “you”/“her”/“him”

(4) “your”/“her”/“his”

(5) YYY

NL 00725.400 “RPY” UTIs – Representative Payee

RPY006 Award Notice to Beneficiary in S8

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

RPY057 Representative Payee Appointed

We have chosen you to be  (1)  representative payee. Therefore  (2)  , you will receive  (3)  checks and use the money for  (4)  needs.

Fill-ins:

(1) “her”/“his”

(2) null/“if [2a] due benefits in the future”

[2a] “she is”/“he is”

(3) “her”/“his”

(4) “her”/“his”

NL 00725.405 “RRB” UTIs – Railroad Retirement Board

RRB001 Number Holder has at Least 120 Months of Railroad Service

The Railroad Retirement Board will make Social Security payments to you. This is because you, your spouse, or the person on whose Social Security record you filed worked for at least 10 years in the railroad industry.

RRB002 RRB Jurisdiction

The Railroad Board will write to let you know when you will get a check and how much it will be. If you are getting a Railroad Retirement annuity, they will also explain any reduction in your annuity because of your Social Security payments.

If you have not already applied for a Railroad Retirement annuity and wish to do so, you must apply at a Railroad Board office. They decide whether you can get an annuity.

The Railroad Retirement board will send you one check each month. This check will include your Social Security benefit and any Railroad Retirement annuity you are due.

NL 00725.410 “RSD” UTIs – Residence

RSD007 Medicare Disallowance - Residency

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

 (4)  may be able to buy Medicare coverage in the future. If  (5)  a citizen of the United States,  (6)  can buy Medicare as soon as  (7)  to this country.

If  (8)  not a citizen,  (9)  can buy Medicare only after  (10)  lived in the United States for five years in a row. These must be the five years right before  (11)  for Medicare. Also, as an alien  (12)  must be lawfully admitted for permanent residence.

Fill-ins:

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

(2) “you”/“she”/“he”

(3) “you”/“she”/“he”

(4) “you”/“she”/“he”

(5) “you are”/“she is”/“he is”

(6) “you”/“she”/“he”

(7) “you return/she returns/he” returns

(8) “you are”/“she is”/ “he is”

(9) “you”/“she”/“he”

(10) “you have”/“she has”/“he has”

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

(12) “you”/ “she”/ “he”

NL 00725.415 “SEI” UTIs – Self-Employment Income

SEIC01 Caption

We Did Not Use Some Of  (1)  Earnings

Fill-in:

(1) SN possessive/“Your”

SEID01 Dictated Text

SEIR01 Income not SEI

We could not use  (1)  income for  (2)  as earnings from self-employment because  (3)  .

Fill-ins:

(1) “your”/Ms. or Mr. plus number holder's last name

*(2) year(s) in the format “YYYY” or “YYYY and YYYY” or “YYYY, YYYY and YYYY”

*(3)

A. Income from renting rooms and apartments is not self-employment income unless special services are given to the tenants

B. a farm owner's share of income usually is not self- employment income when a tenant works the farm

C. Income from renting real estate is not self-employment income unless it is received as part of a real estate dealer's ordinary work

D. Capital gains and losses are not considered self- employment income. Only gains and losses from disposing of inventory can be considered self-employment income

E. Income from the sale of livestock for dairy work or for breeding is not self-employment income

F. not all business deductions were taken. All deductions from income must be taken when a self-employment tax return is filed with the Internal Revenue Service

G. the income was not received from a trade or business. We only consider income received from a trade or business to be self-employment income

H. the income does not meet our requirements to be considered as self-employment income

(*) indicates that the fill-in is manual

SEIR02 SEI Determination Pending

We have not decided whether your income for  (1)  was self-employment income. We will let you know as soon as we make this decision. If we decide that it was self-employment income, we will also tell you if it will increase your benefit.

Fill-in:

(1) Year(s) *

(*) indicates that the fill-in is manual

SEIR03 SEI not Used – Tax Return not Filed Timely

We could not use  (1)  income from self- employment for  (2)  because a federal tax return to report it was not filed on time. To be considered on time, tax returns have to be filed within 3 years, 3 months, and 15 days from the end of the taxable year.

Fill-ins:

(1) SN possessive/“your”

(2) Year(s) *

(*) indicates that the fill-in is manual

SEIR04 SEI not Used – No Proof

We asked you for proof of  (1)  income from self-employment for  (2)  . We have not considered this income because  (3)   (4)  not given us the proof we asked for.

Fill-ins:

(1) SN possessive/“your” *

(2) Year(s)

(3) “you”/“she”/“he” *

(4) “have”/“has” *

(*) indicates that the fill-in is manual

SEIR05 SEI Amount Adjusted

 (1)  reported self-employment income of $  (2)  for  (3)  . We have reduced this to $  (4)  because  (5)  .

Fill-ins:

(1) SN

(2) Old dollar amount *

(3) Year *

(4) New dollar amount *

(5)

a. “income from renting the rooms and apartments is not self-employment income unless special services are given to the tenants” *

b. “a farm owner's share of income usually is not self-employment income when a tenant works the farm”

c. “income from renting real estate is not self-employment income unless it is received as part of a real estate dealer's ordinary work”

d. “capital gains and losses are not considered self-employment income. Only gains and losses from disposing of inventory can be considered self-employment income”

e. “income from the sale of livestock for dairy work or breeding is not self-employment income”

f. “not all business deductions were taken. All deductions from income must be taken when a self-employment tax return is filed with the Internal Revenue Service”

g. “the income was not received from a trade or business. We only consider income received from a trade or business to be self-employment income”

(*) indicates that the fill-in is manual

SEI006 SEI Adjustment Referred to IRS

We will send a copy of our decision about  (1)  self-employment earnings to the Internal Revenue Service. They will make any changes that are needed to the tax record.

Fill-in:

(1) “your”/name

SEIR07 SEI not Used – Under Limit

Net income from self-employment of less than $400 per year is not considered earnings for Social Security purposes. Since we reduced your self-employment income for  (1)  to less than $400, it does not count as Social Security earnings.

Fill-in:

(1) Year *

(*) indicates that the fill-in is manual

NL 00725.420 “SSA” UTIs – Headings and Signatures

SSAH01 First and Second Line Headings

Social Security Administration

Retirement, Survivors and Disability Insurance

SSAH02 Third Line Heading

Notice of Award

SSAH03 Third Line Heading

Notice of Disapproved Claim

SSAH04 Third Line Heading

Claim Information

SSAH05 Third Line Heading

Important Information

SSAH28 Date

Date:

Claim Number:

SSAH30 Payment Name and Address

Addressee

SSAH40 Return Address

Northeastern Program Service Center
155-10 Jamaica Avenue
Jamaica, New York 11432-3898

SSAH41 Return Address

Mid-Atlantic Program Service Center
300 Spring Garden Street
Philadelphia, Pennsylvania 19123-2992

SSAH42 Return Address

Southeastern Program Service Center
1200 Rev. Abraham Woods, Jr. Blvd
Birmingham, Alabama 35285-0001

SSAH43 Return Address

Great Lakes Program Service Center
600 West Madison Street
Chicago, Illinois 60661-2474

SSAH44 Return Address

Western Program Service Center
P.O. Box 2000
Richmond, California 94802-1000

SSAH45 Return Address

Mid-America Program Service Center
601 East Twelfth Street
Kansas City, Missouri 64106-2859

SSAH46 Return Address

Office of Central Operations
1500 Woodlawn Drive
Baltimore, Maryland 21241-1500

SSAH47 Return Address

Office of Central Operations
P.O. Box 17769
Baltimore, Maryland 21235-7769 U.S.A.

Fill-ins for SSAH40 - SSAH47

(1) TELEPHONE CONTACT/CERTIFIED MAIL/null

(2) Actual telephone number in format ###-###-#### if number is available and if fill-in (1) = TELEPHONE CONTACT, otherwise null.

SSAS01 Signature

(Signature of Commissioner of Social Security)

First Name Last Name

Commissioner of Social Security

SSAS02 Signature

Social Security Administration

SSAS03 Signature

Social Security Administration

SSAS04 Signature

Social Security Administration

SSAS05 Signature

Social Security Administration

SSAS06 Signature

Social Security Administration

SSAS07 Signature

Social Security Administration

SSAS08 Signature

Social Security Administration

SSAS09 Signature

Social Security Administration

NL 00725.425 “STU” UTIs – Student Status

STU003 Student Disallowance – Not Attending Approved School

 (1)  not qualify for student's benefits because  (2)  not attending an elementary or secondary level high school which has been approved by a State or local government.

Fill-ins:

(1) “You do”/”She does”/”He does”

(2) “you are”/”she is”/”he is”/”you were”/”she was”/”he was”

STU005 Student Disallowance – Employer Involvement

 (1)  not qualify for student's benefits because  (2)  employer is paying  (3)  to go to school.

Fill-ins:

(1) “You do”/”She does”/”He does”

(2) “your”/”her”/”his”

(3) “you”/”her”/”him”

STUR06 Student Disallowance

 (1)  not qualify for student's benefits because  (2)  imprisoned for the conviction of a crime considered to be a felony.

Fill-ins:

(1) “You do”/”She does”/”He does”

(2) “you are”/”she is”/”he is”

STU007 Student Does not Meet Requirements for Full-time School Attendance

To qualify for student benefits:

 (1)  must be scheduled to attend school at least 20 hours a week, or

The school must consider  (2)  to be in full-time attendance, and

 (3)  course of study must last at least 13 weeks, and

 (4)  must be enrolled in a course that is not a correspondence course.

Fill-ins:

(1) “You”/full name

(2) “you”/”her”/“him”

(3) “your”/”her”/“his”

(4) “you”/”she”/ “he”

NL 00725.430 “SUS” UTIs – Suspensions deleted (for other than work)

SUS001 Benefits Suspended Non-Citizen Outside of U.S. Over 6 Months

We cannot pay  (1)  benefits  (2)   (3)  because  (4)  not a citizen of the United States and  (5)  been living outside the country for more than 6 months. Please read the enclosed pamphlet, “Your Social Security Checks - While You are Outside the United States,” for more information about this.

Fill-ins:

(1) SN/“you”

(2) null/“beginning”

(3) Month and year/null

(4) “you are”/ “she is”/ “he is”

(5) “you have”/“she has”/”he has”

SUS003 Benefits Suspended – U.S. Citizen Outside U.S.

We cannot pay you the benefits  (1)   (2)  due while you live in  (3)  . If  (4)   (5)  to another country, we may be able to begin payments. Please contact us if this happens.

Fill-ins:

(1) SN/“you”

(2) “are”/“is”

(3) Name of country of residence

(4) “you”/“she”/ “he”

(5) “move”/“moves”

SUS004 Benefits Suspended – Non U.S. Citizen Outside U.S.

 (1)   (2)  not due benefits while  (3)   (4)  in  (5)  . If  (6)   (7)  to another country, we may be able to begin payments. Please contact us if this happens.

Fill-ins:

(1) SN/“You”

(2) “are”/“is”

(3) “you”/“she”/ “he”

(4) “live”/“lives”

(5) Name of country of residence

(6) “you”/“she”/“he”

(7) “move”/“moves”

SUS005 Benefits Suspended – Non-Citizen Outside U.S. Over 6 Months (Use with SUS001)

If  (1)   (2)  to the United States for one whole calendar month, we may be able to begin payments. Please contact us if this happens.

Fill-ins:

(1) “you”/“she”/“he”

(2) “return”/“returns”

SUS006 Technical Entitlement – Auxiliary Claim SD

We are stopping the benefits  (1)  been receiving as a  (2)  on  (3)  Social Security record. This is because  (4)  entitled to an equal or larger benefit on  (5)  record.

Fill-ins:

(1) “you have”/“she has”/“he has”

(2) Type of benefit

(3) NH-NAME (possessive)

(4) “you are”/“she is”/“he is”

(5) “your own/her own/his own/another person's”

SUS014 Benefits Suspended – No Child in Care

We cannot pay  (1)  because  (2)  not taking care of a child who  (3)  entitled to Social Security benefits.

Fill-ins:

(1) SN/“you”

(2) ““you are”/“she is”/“he is”/“you were”/“she was”/“he was”

(3) “is”/“was”

SUS017 Benefits Stopped Due to Work

We cannot pay  (1)  because of  (2)  work.

Fill-ins:

(1) SN/“you”

(2) “your”/“her”/“his”

SUS018 Beneficiary or Spouse Entitled to Another GPO

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

Fill-ins:

(1) SN/“you”

(2) “your”/“her”/“his”

(3) “your”/“her”/“his”

SUS021 S8 Award Notice – Beneficiary Non-DAA (Follows CHKC11)

When we begin your  (1)  payments, you will be paid all money that is due you. When we make a decision about your payee, we will send you another letter. This letter will explain what you can do if you disagree with our payee decision.

Fill-in:

(1) Social Security

SUS022 S8 Award Notice – Beneficiary DAA

We will begin your disability payments when we select a payee for you. We will send your payee all money due you. Before we begin payments, we will send another letter telling you whom we selected as your payee. This letter will explain what you can do if you disagree with the payee we selected.

SUS026 S8 Award Notice – Beneficiary Non-DAA

We have determined that you need help managing your payments. We will be selecting a qualified person to receive your payments. We call this person a representative payee. It will be your payee's duty to manage your  (1)  payments for you and use them for your needs.

Fill-in:

(1) Social Security

SUS029 Lead-in Statement – Multiple Suspensions Multiple Periods

We cannot pay  (1)  for  (2)   (3)   (4)  and  (5)   (6)   (7)   (8)  .

Fill-ins:

(1) SN/“you”

(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

SUS030 Lead-in Statement – Multiple Suspensions Multiple Periods

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

Fill-ins:

(1) SN/“you”

(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

SUS031 Lead-in Statement – Multiple Suspensions Multiple Periods

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

Fill-ins:

(1) SN/“you”

(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

SUS057 Alien Not Lawfully Present – Initial No Pay Award

Even though we cannot pay  (1)  benefits, we may be able to pay other individuals if they are entitled on this record.

Fill-in:

(1) “you”/beneficiary full name

SUS060 Number Holder Suspension – Alien Deportation

We cannot pay  (1)  benefits beginning  (2)  because  (3)  been deported. Please let us know if  (4)  permitted to stay in the United States as a resident, because we may be able to pay  (5)  benefits again.

Fill-ins:

(1) SN/“you”

(2) DOST in format “May 1993”

(3) “you have”/“she has”/“he has”

(4) “you are”/“she is”/“he is”

(5) “you”/“her”/“him”

SUS063 Lawful Alien Status Needs Reverification

Based on the information we have,  (1)  lawfully present status will end  (2)  . To receive benefits after that date,  (3)  must give us new evidence by  (4)  about  (5)  status. This evidence must show that  (6)  status has been extended or changed to another lawfully present category. If we do not receive this evidence by  (7)  , we will stop  (8)  benefits.

Fill-ins:

(1) “your”/beneficiary's full name, possessive

(2) date in the format Month DD, YYYY

(3) “you”/“she”/“he”

(4) date in the format Month DD, YYYY

(5) “your”/ “her”/“his”

(6) “your”/“her”/“his”

(7) date in the format Month DD, YYYY

(8) “your”/“her”/“his”

SUS064 Alien Not Lawfully Present – Initial No Pay Award

Based on the information we have,  (1)  not meet the above requirement. We may begin to pay  (2)  benefits if  (3)  alien status changes or if  (4)  the U.S. We will send another letter if we begin  (5)  benefits.

Fill-ins:

(1) “you do”/beneficiary's full name plus “does”

(2) “you”/“her”/“him”

(3) “your”/“her”/“his”

(4) “you leave”/ “she leaves”/ “he leaves”

(5) “your”/“her”/“his”

SUS065 Alien Status

Under the law, we  (1)  pay  (2)  for  (3)  any month  (4)  lawfully present in the U.S. To receive benefits,  (5)  must be a U.S. citizen or national, or lawfully present in the U.S., defined by the Attorney General as an alien;

lawfully admitted for permanent residence;

admitted as a refugee under section 207 of the Immigration and Nationality Act (INA);

granted asylum under section 208 of the INA;

paroled under section 212(d)(5) of the INA (except for aliens paroled for an exclusion hearing or prosecution in the U.S.);

an alien whose deportation has been withheld under section 243 (h) of the INA as in effect prior to April 1, 1997, or whose removal has been withheld under section 241(b)(3) of the INA.

granted conditional entry as a refugee under section 203(a)(7) of the INA as in effect prior to April 1, 1980;

inspected and admitted to the U.S. and who has not violated the applicable terms of his/her status;

with a pending application for political asylum under section 208 of the INA or a pending application for withholding of deportation under section 243(h) of the INA, and employment authorization; or

belonging to any specific class of aliens permitted to remain in the U.S. under U.S. law or policy, for humanitarian or other public policy reasons.

Fill-ins:

(1) “can”/“cannot”

(2) “you”/beneficiary's full name

(3) null

(4) ““you are”/“she is”/ “he is”/you are not/she is not/he is not”

(5) “you”/“she”/“he”

SUS066 Auxiliary Benefits Suspended Pending Development of the Number Holder's CDR Investigation

We cannot pay benefits  (1)   (2)  so we can study the facts and decide whether  (3)  still meets the requirements to receive disability benefits. We will let you know when we make this decision and will tell you whether we can start  (4)  benefits again.

Fill-ins:

(1) “beginning”

(2) MMYYYY

(3) NH-Name

(4) BGN possessive/BGN plus BLN possessive/“your”

SUS069 Notify the Disabled Claimant that His/Her Benefits are being Suspended Pending Development for a Continuing Disability

We cannot pay  (1)  benefits because our records show that  (2) 

did not return information we asked for; or

 (3)  returned to work; or

 (4)  health improved; or

 (5)  could not be located.

We cannot pay benefits because we must study the facts and decide whether  (6)  still  (7)  the requirements to receive disability benefits.

Fill-ins:

(1) BGN plus BLN/”you”

(2) “he”/“she”/“you”

(3) “he”/“she”/“you”

(4) “his”/“her”/“your”

(5) “he”/“she”/“you”

(6) “he”/“she”/“you”

(7) “meets”/ “meet”

SUS070 Benefits Suspended Pending Development of Correct Address or Beneficiary's Whereabouts Unknown

We cannot pay  (1)  starting  (2)  . We need more information before we can start  (3)  payments again.

Fill-ins:

(1) “you”/FN

(2) Date (Month and Year)

(3) “your”/ “his”/ “her”

SUS077 Ongoing Voluntary Suspension to Earn Delayed Retirement Credits (VOLDRC or LEGIS1)

We received  (1)  request to suspend  (2)  retirement benefits to earn delayed retirement credits. Suspending these benefits will also stop payments to  (3)  on any other record on which  (4)  entitled. We will restart  (5)  benefits with the earlier of:

  • The month  (6)  age 70, or

  • The month after  (7)  for payments to restart.

Fill ins:

(1) “your”/ Number holder's BGN plus BLN (possessive)

(2) “your”/”his”/ “her”

(3) “you”/”him”/ “her”

(4) “you are”/ “he is”/ “she is”

(5) “your”/ Number holder's BGN plus BLN (possessive)

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

(7) “you ask”/ “he asks”/ “she asks”

SUS079 Beneficiary Requests Waiver of His Right to Benefit Payments

We are withholding  (1)  benefits because  (2)  requested us to do so.

Fill-ins:

(1) BGN plus BLN possessive/”your”

(2) “he has”/“she has”/“you have”

SUS081 Beneficiary's Benefits Will be Suspended because of an Administrative Sanction

We notified  (1)  earlier that we would withhold some benefits if  (2)  became entitled to Social Security benefits. Under Social Security rules we will not pay a person Social Security benefits for a certain period of time if that person:

Made a statement or presented a material fact that the person knew or should have known was false or misleading, and we used the information to decide entitlement or payment amounts; or

Omitted material facts that the person knew or should have known we needed when we decided entitlement or payment amounts.

When we do not pay the person, we call this a penalty. As a result we are withholding  (3)  benefits from  (4)  through  (5)  .

Fill-ins:

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

(2) “she”/“he”/“you”

(3) “her”/“his”/“your”

(4) Month YYYY

(5) Month YYYY

SUS084 Embedded Period of Voluntary Suspension to Earn Delayed Retirement Credits (VOLDRC or LEGIS1)

We received  (1)  request to suspend  (2)  retirement benefits for  (3)  to earn delayed retirement credits. Suspending these benefits will also stop payments to  (4)  on any other record on which  (5)  entitled. We will restart  (6)  benefits for  (7)  in  (8)  unless  (9)  us to restart  (10)  benefits earlier.

Fill-ins:

(1) “your”/ Number holder's BGN plus BLN (possessive)

(2) “your”/ “his”/ “her”

(3) Month CCYY/ Month CCYY through Month CCYY

(4) “you”/ Number holder's name BGN plus BLN (not possessive)

(5) “you are”/ “he is”/ “she is”

(6) “your”/ Number holder's name BGN plus BLN (possessive)

(7) Month CCYY of restart of benefits

(8) Month CCYY of first payment after restart of benefits

(9) ”you ask”/ “he asks”/ “she asks”

(10) “your”/ “his”/ “her”

SUS085 Suspension of Benefits Due to Alien Deportation or Removal from the U.S. – Number Holder

We cannot pay  (1)  benefits beginning  (2)  because  (3)  been deported or removed from the United States under one of the following sections of the Immigration and Nationality Act (INA):

Section 241(a) of the INA in effect prior to April 1, 1997;

Section 237(a); or

Section 212(a)(6)(A).

Please let us know if in the future  (4)  permitted to return to the United States as a lawful permanent resident. We may be able to pay  (5)  benefits at that time.

Fill-ins:

(1) Ms. Plus BLN/Mr. plus BLN/ “you”

(2) Show the DOST in the format Month, YYYY

(3) “she has”/“he has”/“you have”

(4) “she is”/“he is”/ “you are”

(5) “her”/“him”/ “you”

SUS086 Suspension of Auxiliary/Survivor Benefits Due to Number Holder's Alien Deportation or Removal from the U.S.

No benefits are payable to  (1)  beginning  (2)  because  (3)  has been deported or removed from the United States.

Benefits may be payable if  (4)   (5)  a U.S. citizen or  (6)   (7)  in the United States for a full calendar month or more without leaving for any period, no matter how short. Please let us know if either of these things happen.

Fill-ins:

(1) Beneficiary's given name (BGN)/ plus BLN/”you”

(2) Show the DOST in the format Month, YYYY

(3) Show the NH's full name

(4) BGN/BGN plus BLN/”you”

(5) “becomes”/ “become”

(6) “she”/ “he”/ “you”

(7) “stays”/ “stay”

SUS100 Suspension of Auxiliary's Benefits – Number Holder (NH) Requests Voluntary Suspension to Earn Delayed Retirement Credits (LEGIS1)

We received  (1)  request to suspend  (2)  benefits to earn delayed retirement credits. As a result, we must suspend the benefits  (3)  on  (4)  record. We will restart  (5)  benefits with the earlier of:

  • The month  (6)  reaches age 70, or

  • The month after  (7)  asks for payments to restart.

Fill-ins:

(1) Number holder's BGN plus BLN (possessive)

(2) “his”/ “her”

(3) “you receive”/Auxiliary's BGN plus BLN (not possessive) plus “receives”

(4) Number holder's BGN plus BLN (possessive)

(5) “your”/Auxiliary's BGN plus BLN (possessive)

(6) Number holder's BGN plus BLN (not possessive)

(7) Number holder's BGN plus BLN (not possessive)

NL 00725.435 “TAX” UTIs – Taxation of Benefits

TAXC01 CAPTION

Living In A Foreign Country Affects Benefits

TAXC04 CAPTION

Your Benefits May Be Taxed

TAXD01 Dictated Text

TAX002 Alien Tax Withheld

We will withhold federal income tax from  (1)  benefit each month starting  (2)  .

If  (3)  a U.S. resident, please let us know and we will stop withholding the tax.

The United States has income treaties with Canada, Egypt, Germany, India, Ireland, Israel, Italy, Japan, Romania, Switzerland and the United Kingdom that may reduce or eliminate this tax on Social Security benefits for certain residents of these countries. Please contact the Internal Revenue Service to learn more about these treaties. Please contact us to stop or reduce the tax if  (4)  the conditions of an income tax treaty.

Fill-ins:

(1) “your”/”beneficiary's full name, possessive”

(2) date in the format Month CCYY

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

(4) “you meet”/“he meets”/“she meets”

TAX003 Alien Tax Withheld

We use information about  (1)  citizenship and residency to decide whether to withhold federal income tax from  (2)  benefits. If you think we have wrong information, please contact us.

We collect this tax for the Internal Revenue Service (IRS). If you have questions about this tax, or to learn about  (3)  or appeal rights, please contact the IRS.

Fill-ins:

(1) “your”/”beneficiary's full name, possessive”

(2) “your”/”his”/”her”

(3) “your”/“beneficiary's full name, possessive”

TAX028 Notification of Potential Tax Liability

You may have to pay taxes on the benefits you get from us. Part of your Social Security benefits may be taxed if:

  • you are single and your total income is more than $25,000 or

  • you are married and you and your spouse have total income of more than $32,000.

You can decide if you want to have federal taxes withheld from your benefits. If you want taxes withheld, you need to complete and return a Form W-4V, Voluntary Withholding Request. You can get Form W-4V from the Internal Revenue Service by calling 1-800-829-3676. You can also get this form at  (1)  on our website. After you complete and sign the form, return it to your local Social Security office by mail or in person.

You can find more information on paying taxes in the enclosed pamphlet,  (2)  .

Fill-ins:

(1) www.social security.gov/planners/taxes.htm

(2) “What You Need To Know When You Get Social Security Disability Benefits”/“What You Need to Know When You Get Retirement or Survivors Benefits”

NL 00725.440 “TER” UTIs – Terminations

TER001 Terminated – Not Student/Not Disabled

 (1)   (2)  no longer entitled to Social Security benefits beginning  (3)  .  (4)  benefits are stopping because in that month  (5)  :

 (6)  years old, and

not disabled, and

not a full-time elementary or secondary level school student.

Fill-ins:

(1) SN/“You”

(2) “is”/“are”

(3) Month of termination, in format “June 1991”

(4) “your”/“her”/“his”

(5) “you are”/ “she is”/ “he is”

(6) “18”/“19”

TER002 Terminated – No Longer Student

 (1)   (2)  no longer entitled to Social Security benefits beginning  (3)  .  (4)  benefits are stopping in that month because:

 (5)  not a full-time elementary or secondary level school student and,

 (6)  not disabled.

Fill-ins:

(1) SN/“You”

(2) “is”/“are”

(3) Month of termination in format “June 1991”

(4) “your”/ “her”/ “his”

(5) “you are”/“she is”/“he is”

(6) “you are”/“she is”/“he is”

TER003 Terminated – Student Age 19

 (1)   (2)  no longer entitled to student benefits beginning  (3)  . Student benefits normally end with the payment before the month the student turns 19. But,  (4)  met an exception which allowed benefits to continue past that month. The exception allows benefits to continue for two months after the student turns 19, or until the end of the school term, whichever comes first.

However, if the school requires a student to reenroll each quarter or semester, benefits may continue until that quarter or semester ends.  (5)  no longer  (6)  the exception beginning  (7)  , so  (8)  student benefits end that month.

Fill-ins:

(1) “You”/beneficiary's name

(2) “is”/“are”

(3) Month of termination in format “June 1991”

(4) “you”/“she”/“he”

(5) “you”/“she”/“he”

(6) “meet”/“meets”

(7) Month of termination in format “July 1991”

(8) “your”/“her”/“his”

TER004 Termination of Benefits

 (1)   (2)  not entitled to benefits beginning  (3)  because  (4)  in that month.

Fill-ins:

(1) SN/“You”/beneficiary's name

[4a] “you”/“she”/“he”

(2) “is”/“are”

(3) Month in format “July 1991”

(4)

[4a] “remarried”/“(4b) divorced”/“(4c) married”/“[4d] died”

[4b] “you”/“she”/“he”

[4c] “you”/“she”/“he”

[4d] “she”/ “he”

TER006 Dual Entitlement Benefits Terminate (T5)

 (1)  no longer entitled to benefits beginning  (2)  because  (3)  entitled to an equal or larger benefit on another record.

Fill-ins:

(1) Beneficiary's Name “is”/“You are”

(2) Effective date in format May 1997

(3) “you are”/“she is”/“he is”

TER007 Terminated – No Child in Care

 (1)  no longer entitled to Social Security benefits beginning  (2)  . To be entitled,  (3)  must be taking care of a child who is entitled to benefits. That child must be under age 16 or disabled. In  (4)  ,  (5)  child  (6)   (7)  .

Fill-ins:

(1) “you are”/“she is”/“he is”

(2) Month of termination in format “July 1991”

(3) “you”/“she”/“he”

(4) Month of termination in format “July 1991”

(5) “your”/“her”/“his”

(6) child's name

(7) “got married”/“died”/”became age 16”/”was no longer entitled to disability benefits”

NL 00725.445 “TOT” UTIs – Totalization

TOT004 U.S. Benefit Based on U.S. Credits Alone

 (1)  for benefits using work covered by the U.S. only. Under our agreement with  (2)  , no U.S. benefits may be paid using work covered by  (3)  if  (4)  for benefits without it.

Fill-ins:

(1) “You qualify”/Ms. plus NH-last name plus “qualifies/Mr. plus NH-last name plus “qualifies”

(2) Name of the country(ies) in one of the following formats: “Country”/“Country and Country”/“Country, Country and Country”/“Country, Country, Country and Country”

(3) Name of the country(ies) in one of the following formats: “Country”/“Country and Country”/“Country, Country and Country”/“Country, Country, Country and Country”

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

TOTR04 U.S. Benefit Based on U.S. Credits Alone

 (1)  for benefits using work covered by the U.S. only. Under our agreement with  (2)  , no U.S. benefits may be paid using work covered by  (3)  if  (4)  for benefits without it.

Fill-ins:

(1) “You qualify”/Ms. plus NH-last name plus “qualifies”/Mr. plus NH-last name plus “qualifies”

(2) Name of the country(ies) in one of the following formats: “Country”/“Country and Country”/“Country, Country and Country”/Country, Country, Country and Country”

(3) Name of the Country(ies) in one of the following formats: “Country”/“Country and Country”/“Country, Country and Country”/“Country, Country, Country and Country”

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

TOT005 Introductory Statement When the Beneficiary is being Denied for a Factor of Entitlement other than Insured Status and also When the Claimant is being Denied and the Decision Applies to Both Regular and Totalization Benefits

This decision applies to  (1)  claim for both regular U.S. benefits and U.S. benefits under the Social Security agreement with  (2)  .

Fill-ins:

(1) “your”/beneficiary's full name, possessive

(2) Name of the country(ies) in one of the following formats: “Country”/“Country and Country”/“Country, Country and Country”/“Country, Country, Country and Country”

TOT006 Disallowed Both Regular and Totalization Benefits

 (1)  at least six credits under the U.S. Social Security program before we can give  (2)  credit for coverage in another country. Since  (3)  less than six U.S. credits, we did not count any credits in  (4)  .

Fill-ins:

(1) “You need”/Ms. plus NH-last name plus “needs”/Mr. plus NH-last name plus “needs”

(2) “you”/“her”/“him”

(3) “you have”/“she has”/“he has”

(4) Name of the country(ies) in one of the following formats: “Country”/“Country and Country”/“Country, Country and Country”/“Country, Country, Country and Country”

TOT007 Disallowed Claim – Foreign Credits were not Yet Considered

We based our decision on  (1)  U.S. work credits. We did not look at the work credits  (2)  may have earned in  (3)  .  (4)  may still be eligible for U.S. Social Security retirement benefits based on combined U.S. and foreign credits. We will send  (5)  another letter after we consider foreign work credits.

Fill-ins:

(1) “your”/FN possessive

(2) “you”/FN

(3) Name of the country(ies) in one of the following formats: “Country”/”Country and Country”/”Country, Country and Country”/”Country, Country, Country and Country”

(4) “You”/FN

(5) “you”/FN

TOT008 Disallowance for Paid Benefits because Beneficiary has not Worked Long Enough Under U.S. Social Security

 (1)  not worked long enough to qualify for benefits covered by the U.S. Social Security program. We will work with  (2)  to determine any work credits  (3)  earned in  (4)  . When we know the number of foreign credits earned, we will send  (5)  a separate notice to let  (6)  know if  (7)  eligible for U.S. benefits based on combined U.S. and foreign credits.

Fill-ins:

(1) “You have”/FN plus “has”

(2) Name of country(ies) in one of the following formats: “Country”/“Country and Country”/“Country, Country and Country”/“Country, Country, Country and Country”

(3) “you”/FN

(4) Name of country(ies) in one of the following formats: “Country”/“Country and Country”/“Country, Country and Country”/“Country, Country, Country and Country

(5) “you”/FN

(6) “you”/FN

(7) “you are”/FN plus “is”

TOT010 Claimant has also Filed for Benefits from a Foreign Country

 (1)  application is also a claim for social insurance benefits from  (2)  .  (3)  will let you know if  (4)  for benefits under  (5)  laws.

Fill-ins:

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

(2) Name of country(ies) in one of the following formats: “Country”/“Country and Country”/“Country, Country and Country”/“Country, Country, Country and Country”

(3) That country/Those countries

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

(5) “its”/“their”

NL 00725.450 “TWP” UTIs – Trial Work Period

TWPR01 Trial Work Period and Work Continuing

The Social Security law provides a trial work period so that  (1)  can test  (2)  ability to work, despite  (3)  impairment, without losing benefits. The trial work period may last as long as 9 months in which  (4)   (5)  for earnings of more than $  (6)  a month or  (7)  self-employment earnings of $  (8)  a month or spend more than 80 hours a month in self-employment. These 9 trial work service months, as they are called, may be consecutive or they may be separated by months in which  (9)  not working at all.

According to the information reported to us,  (10)  ninth service month will be  (11)  . At that time you will be contacted for further information about  (12)  work and the amount of earnings.  (13)  case will then be reviewed to see whether  (14)  still disabled within the meaning of the law. A person's disability ends if  (15)  becomes able to do substantial gainful work. [At the present time, earnings over $  (16)  a month will be considered substantial and gainful.] If it is determined that  (17)  still disabled,  (18)  benefits will continue. If  (19)  disability ends,  (20)  will receive benefits for an additional 3 months. The law also provides that entitlement to disability benefits shall end if it is determined that an individual's medical condition is no longer severe enough to prevent  (21)  from working. In such cases, the trial work period ends upon recovery. However, even if the trial work period is thus ended  (22)  will receive 3 additional months benefits.

Fill-ins:

(1) FN/“you”

(2) “your”/“her”/“his”

(3) “your”/“her”/“his”

(4) “you”/“she”/“he”

(5) “work”/“works”

(6) Money amount *

(7) “have”/“has”

(8) Money amount *

(9) “you are”/“she is”/ “he is”

(10) FN, possessive/your

(11) 9 TWP service month/year *

(12) “your”/“her”/“his”

(13) “your”/“her”/“his”

(14) “you are”/“she is”/ “he is”

(15) “she”/“he”

(16) Current SGA amount *

(17) “you are”/“she is”/“he is”

(18) “your”/“her”/“his”

(19) “your”/“her”/“his”

(20) “you”/“she”/“he”

(21) “her”/“him”

(22) “you”/“she”/“he”

(*) indicates that the fill-in is manual

TWPR02 Trial Work Period and Work Ceased

The Social Security law provides a trial work period so that  (1)  can test  (2)  ability to work, despite  (3)  impairment, without losing benefits. The trial work period may last as long as 9 months in which  (4)   (5)  for earnings of more than $  (6)  a month or  (7)  self-employment earnings of $  (8)  a month or spend more than 80 hours a month in self-employment. These 9 trial work service months, as they are called, may be consecutive or they may be separated by months in which  (9)  not working at all. At the end of these 9 months, a person's case is reviewed to see whether  (10)  is still disabled within the meaning of the law. Disability ends if a person becomes able to do substantial gainful work. [At the present time, earnings over $  (11)  a month will be considered substantial and gainful.] If it is determined that a person is still disabled, benefits will continue. If disability ends, benefits will be paid 3 additional months.

The law also provides that entitlement to disability benefits shall end if it is determined that an individual's medical condition is no longer severe enough to prevent  (12)  from working. In such cases, the trial work period ends upon recovery. However, even if the trial work period is thus ended, benefits will be paid for 3 additional months.

The information reported to us shows that  (13)  worked in  (14)   (15)  of  (16)  trial work period. You should notify us promptly if you believe that  (17)  recovered from  (18)  disability or  (19)  returned to any type of work.

Fill-ins:

(1) FN/“you”

(2) “your”/“her”/“his”

(3) “your”/“her”/“his”

(4) “you”/“she”/ “he”

(5) “work”/“works”

(6) Money amount *

(7) “have”/“has”

(8) Money amount *

(9) “You do”/“She does”/ “He does”

(10) “she/he”

(11) Current SGA amount *

(12) “her/him”

(13) “you”/“she”/“he”

(14) TWP elapsed service months in format “9” *

(15) “month”/“months”

(16) your/“her”/“his”

(17) “you have”/“she has”/“he has”

(18) “your”/“her”/“his”

(19) “you”/“she”/“he”

(*) indicates that the fill-in is manual

NL 00725.460 ‘VRN” UTIs – Vocational Rehabilitation

VRN005 State Vocational Rehabilitation Services are Available (All DIB Denials)

If you want to ask about counseling, training, and other services to help you in going to work, contact the nearest State vocational rehabilitation office. Their phone number is in the blue pages of your telephone book under State Government. You can also go to our Office of Employment Support Programs' website at  (1)  . Click on the State where you live and it will provide your local vocational rehabilitation agency's address and telephone number.

VRN006 Referral to a State Agency for Vocational Rehabilitation Services

A vocational rehabilitation or employment services provider may contact  (1)  to help  (2)  in going to work. The provider may be from a State agency or work under contract with Social Security.

If  (3)  to work, we have special rules that let us continue  (4)  cash payments and health care coverage. To learn more about how work and earnings affect disability benefits, visit our website at  (5)  .

 (6)  may also call or visit any Social Security office to ask for the following publications:

  • Social Security - Working While Disabled...How We Can Help (SSA Publication No. 05-10095); and

  • Social Security - If You Are Blind--How We Can Help (SSA Publication No. 05-10052).

Fill-ins:

(1) “you”/FN

(2) “you”/“him”/“her”

(3) “you go”/FN plus “goes”

(4) “your”/“his”/“her”

(5) www.socialsecurity.gov/work/

(6) “You”/“He”/“She”

NL 00725.465 “VTW” UTIs – Voluntary Tax Withholding

VTW001 General (Beneficiary's Requested Start Dates and Rates)

You asked that we withhold money from  (1)  benefits for voluntary Federal tax withholding. You want  (2)   (3)   (4)   (5)   (6)   (7)   (8)   (9)   (10)   (11)   (12)   (13)   (14)   (15)   (16)   (17)   (18)   (19)  .

Fill-ins:

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

(2) 7 percent/15 percent/28 percent/31 percent/null

(3) “withheld”/null

(4) “beginning”/“for”/null

(5) Date in the format September 1995/null

(6) “and”/“through”/null

(7) Date in the format September 1995/null

(8) “,”/and/null

(9) 7 percent/15 percent/28 percent/31 percent/null

(10) “withheld”/null

(11) “beginning”/“for”/null

(12) Date in the format September 1995/null

(13) “and”/“through”/null

(14) Date in the format September 1995/null

(15) “and”/null

(16) 7 percent/15 percent/28 percent/31 percent/null

(17) “withheld”/null

(18) “beginning”/null

(19) Date in the format September 1995/null

VTW002 Start Withholding (Current Benefits)

We will withhold $  (1)  from  (2)  benefit for  (3)  . Thereafter, we will withhold $  (4)  each month.  (5)   (6) 

Fill-ins:

(1) Money fill-in

(2) “your”/Beneficiary's Name possessive

(3) Date fill-in

(4) Money fill-in

(5) “We will continue to withhold until”/null

(6) Date fill-in/null

VTW003 Voluntary Tax Withholding from PMA

We will withhold $  (1)  from  (2)  next check. This check is the money  (3)  due through  (4)  .

Fill-ins:

(1) Money fill-in

(2) “your”/Beneficiary's Name possessive

(3) “you are”/“she is”/ “he is”

(4) Date fill-in

VTW004 Stopped Withholding but Resume in Future

We will not withhold money for voluntary Federal tax withholding from  (1)  monthly Social Security benefits beginning  (2)  through  (3)  .

Fill-ins:

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

(2) Date fill-in

(3) Date fill-in

VTW005 Not Enough for Withholding

Since the amount due  (1)   (2)   (3)  is not enough for voluntary Federal tax withholding, we cannot honor your request.

Fill-ins:

(1) “you”/Beneficiary's Name

(2) “through”/“for”/“from”/null

(3) Date fill-in

VTW006 Stopped Withholding

As you asked, we will stop voluntary Federal tax withholding from  (1)  monthly Social Security benefit beginning  (2)  .

Fill-ins:

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

(2) Date fill-in

NL 00725.470 “WCP” UTIs – Workers’ Compensation

WCPC01 Caption

Other Disability Payments Affect Benefits

WCP001 WC/PDB – Number Holder Expressed Intent to File for WC/PDB

We learned that  (1)  to file a claim for workers' compensation or public disability benefit. If  (2)  these payments, we may have to reduce  (3)  Social Security benefits.

At that time,  (4)  may have to pay back any Social Security benefits that  (5)  not due. If  (6)  a claim, please tell us the decision made on the claim right away.

Fill-ins:

(1) NH FN “plans”/“you plan”

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

(3) “your”/“your and your family's”/“his and his family's”/“her and her family's”/“his”/“her“

(4) “you”/“you and your family”/“he”/“he and his family”/“she“/“she and her family”

(5) “you were”/“he was”/“she was”/“you and your family were”/“he and his family were”/“she and her family were“

(6) “you file”/“he files”/“she files”

WCP003 WC/PDB – Definition of WC/PDB Offset

We have to consider workers' compensation and/or public disability payments when we figure a Social Security benefit. The following will explain how these payments affect Social Security benefits. For more information, please read the enclosed pamphlet, “How Workers' Compensation and Other Disability Benefits May Affect Your Social Security Benefit.”

WCP004 WC/PDB – Number Holder Receiving WC/PDB – No Offset

 (1)  present  (2)  payments of $  (3)  do not affect  (4)  Social Security benefits.

Fill-ins:

(1) NH FN possessive/“Your”

(2) “workers' compensation”/“public disability”/“workers” compensation and public disability”

(3) Money amount

(4) “your”/“you and your family's”/“his”/“his and his family's”/“her”/“her and her family's”

WCP005 WC/PDB – Offset Determined by ACE

The pamphlet explains how we reduce  (1)  Social Security disability benefits. We add the money  (2)  would receive from us and from  (3)  . When this total adds up to more than 80 percent of  (4)  average current monthly earnings, we reduce  (5)  Social Security disability benefits. We found that 80 percent of  (6)  average current monthly earnings is  (7)  .

Fill-ins:

(1) “your”/“your and your family's”/“your family's”/“NH name possessive”/“NH name “and his family's”/“NH name “and her family's”/“NH's name possessive plus “family's”

(2) “you“/'he”/”she”/“you and your family“/“he and his family”/“she and her family”

(3) “workers' compensation”/“public disability benefit payments”/“workers' compensation and public disability benefit payments”

(4) “your”/”his”/”her”

(5) “your”/“your and your family's”/“your family's”/“her”/”his”/“her and her family's”/“his and his family's”/“her family's”/”his family's”

(6) “your”/”his”/”her”

(7) Money amount

WCPR06 WC/PDB – Amount of Offset Based on Estimate for 1 or More Years High 1

When we figured how much to reduce  (1)  benefits, we used an estimate for part of  (2)  earnings before  (3)  became disabled. According to our records, the year in which  (4)  earned the most money between  (5)  and  (6)  was  (7)  . We estimated  (8)  earnings for that year to be $  (9)  . If  (10)   (11)  that this amount is wrong, please let us know.  (12)  will also need to give us any facts  (13)  to show that the amount is wrong.

Fill-ins:

(1) “your”/“your and your family's”/“your family's”/“NH name possessive”/“NH name possessive “and his family's”/“NH name possessive “and her family”/“NH's name possessive plus “family's”

(2) “your”/“her”/“his”

(3) “you”/“she”/“he”

(4) “you”/“she”/“he”

(5) Date of onset minus 5 years in the format “YYYY”

(6) Date of onset in the format YYYY

(7) Year of highest regular earnings in the format “YYYY”

(8) “your”/“her”/“his”

(9) Highest regular earnings in the format “$$$$$.¢¢”

(10) “you”/“she”/“he”

(11) “think”/“thinks”

(12) “you”/“she”/“he”

(13) “you have”/“she has”/“he has”

WCPR07 WC/PDB – Amount of Offset Based on Estimate for 1 or More Years – High 5

When we figured how much to reduce  (1)  benefits, we used an estimate for part of  (2)  earnings before  (3)  became disabled. According to our records, the 5 years in which  (4)  earned the most money were  (5)  to  (6)  . We estimated that  (7)  earned $  (8)  during this period. If  (9)  that this amount is wrong, please let us know.  (10)  will also need to give us any facts  (11)  to show that the amount is wrong.

Fill-ins:

(1) “your”/“your and your family's”/“your family's”/“NH name possessive”/“NH name possessive “and his family's”/“NH name possessive “and her family's”/“NH's name possessive plus “family's”

(2) “your”/“her”/“his”

(3) “you”/“she”/“he”

(4) “you”/“she”/“he”

(5) Year in the format “YYYY” *

(6) Year in the format “YYYY” *

(7) “you”/“she”/“he”

(8) Money amount in the format $$$$$.¢¢ *

(9) “you think”/NH name “thinks”

(10) “you”/“she”/“he”

(11) “you have”/“she has”/“he has”

(*) indicates that the fill-in is manual

WCP007 Number Holder Appealing WC/PDB Decision (Auxiliary Only)

We will not reduce  (1)  benefit because of  (2)   (3)  payments until a decision is made on the appeal of the claim. At that time, we may collect any money that should not have been paid.

Fill-ins:

(1) BGN plus BLN, possessive/your

(2) NH-NAME, possessive

(3) “workers' compensation”/”public disability”/”worker's compensation and public disability”

WCP008 WC/PDB - WC/PDB Claim Pending – Auxiliary Only

If  (1)  receives workers' compensation and/or public disability payments, we may have to reduce  (2)  Social Security benefits. At that time, we may also have to recover any money that should not have been paid.

Fill-ins:

(1) NH name

(2) FN possessive/“your”

WCPR09 WC/PDB – Interim Notice – Pending ACE Determination

We may have to change the amount of  (1)  benefits when we receive proof of the amount of  (2)  average current earnings. We use these earnings to figure how much to deduct from  (3)  benefits.

Fill-ins:

(1) FN possessive/“your”

(2) NH name possessive/“your“/“her”/“his”

(3) “your”/“her”/“his”/FN possessive

WCP009 Number Holder Appealing WC/PDB Decision (Number Holder Only)

We will not reduce  (1)  benefit because of  (2)  payments until  (3)  a decision on  (4)  appeal of the claim. Please let us know the decision on the appeal right away. At that time,  (5)  may have to pay back any Social Security benefits that  (6)  not due.

Fill-ins:

(1) BGN plus BLN possessive/“your”

(2) “workers' compensation”/”public disability benefit”/”worker's compensation and public disability benefit”

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

(4) “your”/“his”/“her”

(5) “you”/“he”/“she”

(6) “you were”/“he was”/“she was”

WCP010 WC/PDB – Total or Partial WC/PDB Offset – Number Holder Only

We have to take into account  (1)   (2)  of $  (3)   (4)   (5)  when we figure  (6)  Social Security benefits. Due to this payment, we are  (7)   (8)  benefits.

Fill-ins:

(1) your/Numberholder's BGN plus BLN (possessive)

(2) “workers' compensation payment”/“public disability payment”/“workers' compensation and public disability payment”

(3) Money amount

(4) “beginning”/“for”

(5) “Month YYYY”/Month YYYY plus through plus Month YYYY”

(6) “your”/“his”/”her”

(7) “withholding”/“reducing”

(8) “your”/“his”/“her”

WCP011 WC/PDB – Total or Partial Offset – Auxiliary Only

We have to take into account  (1)   (2)  payments when we figure  (3)  Social Security benefits. We are  (4)  the benefits  (5)  due because of these payments.

Fill-ins:

(1) NH name possessive

(2) “workers' compensation”/“public disability”/“workers' compensation and public disability”

(3) FN possessive/“your”

(4) “withholding”/“reducing”

(5) “you are”/“she is”/“he is”

WCP012 WC/PDB –Offset Imposed First Month Number Holder Received DIB and WC/PDB

We are  (1)   (2)  monthly payment beginning  (3)  . This is the first month when  (4)  entitled to Social Security disability benefits and  (5)  payments.

Fill-ins:

(1) “withholding”/“reducing”

(2) null plus FN possessive/”your”

(3) Show the month and year withholding or reduction began in the format “Month YYYY”

(4) “he is”/“she is”/ “you are”

(5) “workers' compensation”/“public disability”/“both workers' compensation and public disability”

WCPR13 WC/PDB Offset Imposed After Date of Notice

We are reducing  (1)  benefits beginning  (2)  because of workers' compensation payments. We must reduce benefits beginning with the month after the month in which we were told about these payments.

Fill-ins:

(1) NH name [possessive]/NH first name possessive/BGN plus BLN possessive/“your”

(2) First month and year of offset in the format “May 1999”

WCP013 Change in Reduction of WC/PDB Due to Change in State Law (Reverse Jurisdiction)

Beginning  (1)  , we are paying  (2)  a Social Security benefit that is not reduced due to  (3)  payments. This is because of a change caused by the State law which provides for the reduction of these payments to persons who receive Social Security disability benefits.

Fill-ins:

(1) Month YYYY

(2) “you”/BGN plus BLN

(3) “worker's compensation”/”public disability”/”workers' compensation and public disability”

WCP014 WC/PDB – Amount of Benefit Received after Offset

 (1)  benefit will be $  (2)  beginning  (3)  .

Fill-ins:

(1) NH first name (possessive)/NH given name plus last name (possessive)/Beneficiary Full name (possessive)/“Your”

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

(3) Month of offset in the format “December 1999”

WCPR15 WC/PDB – Number Holder in Offset Due to Receipt of WC/PDB – Adjustment Made

We are  (1)   (2)  benefits beginning  (3)  , when  (4)   (5)  payments changed from $  (6)  to $  (7)  .

Fill-ins:

(1) “withholding”/“reducing”

(2) NH FN possessive/“your”

(3) Date *

(4) “your”/“her”/“his”

(5) “workers' compensation”/“public disability”/“workers' compensation and public disability”

(6) Prior money amount *

(7) Current money amount *

(*) indicates that the fill-in is manual

WCPR16 WC/PDB – Auxiliary in Offset Due to Number Holder Receipt of WC/PDB Adjustment Necessary

We are  (1)   (2)  benefits beginning  (3)  , when the  (4)  payments changed.

Fill-ins:

(1) “withholding”/“reducing”

(2) FN possessive/BGN possessive

(3) Month and year *

(4) “workers' compensation”/“public disability“/“workers' compensation and public disability”

(*) indicates that the fill-in is manual

WCP017 WC/PDB – Increase in Benefit After WC/PDB First Imposed

 (1)  benefits were increased beginning  (2)   (3)   (4)  .  (5)  not reduced because of  (6)  payments.

Fill-ins:

(1) NH SN name (possessive)/BGN plus BLN possessive/BGN possessive/“Your”

(2) Earliest month/year

(3) “and”/null

(4) Month and year/null

(5) “This increase was”/“These increases were”

(6) “workers' compensation”/“public disability”/“workers' compensation and public disability”

WCP018 WC/PDB – Removal of Offset - WC/PDB Terminated

We do not reduce benefits once  (1)  payments have stopped. Therefore, we are paying benefits at the full rate beginning  (2)  . Please let us know right away if  (3)  workers' compensation and/or other public disability payments.

Fill-ins:

(1) “workers' compensation”/ “public disability”/“workers' compensation and public disability”

(2) Month and year in the format “September 1999”

(3) NH name “receives”/“you receive”

WCP019 WC/PDB – Removal of Offset – Number Holder Age 62 or 65 (Before 12/19/2015)

Beginning  (1)  , we are not reducing  (2)  benefits because of  (3)  payments. We do not reduce benefits for months when the disabled worker is age  (4)  or over.

Fill-ins:

(1) Month and year NH attains 65 in format “July 2012”

(2) NH SN possessive/BGN plus BLN possessive/BGN possessive/“your”

(3) “workers' compensation”/“public disability”/“workers' compensation and public disability”

(4) “65”

WCPR20 Workers' Compensation – Lump Sum and Ending Date of Proration

We changed  (1)  monthly benefit because  (2)  received a  (3)  lump-sum award. We treat a lump-sum award as if it were paid on a weekly basis. We  (4)  a full Social Security benefit to  (5)  beginning  (6)  .

Fill-ins:

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

(2) “she”/“he”/“you”/FN

(3) “workers' compensation”/“public disability”/“workers' compensation and public disability”

(4) “will pay”/“started paying”

(5) “her”/“him”/“you”

(6) Month and year in the format March 1999

WCP021 WC/PDB –Possible Excludable Expenses

If  (1)  had any expenses related to  (2)  claim for  (3)  payments, please give us proof that  (4)  paid these expenses. We may be able to deduct some of these expenses when we figure  (5)  Social Security benefits.

Fill-ins:

(1) NH FN/“you”

(2) “your”/”his”/”her”

(3) “workers' compensation”/” workers' compensation and public disability benefit”/ “public disability benefit”

(4) “you”/“he”/“she”

(5) “your and your family's”/“NH name possessive”/ “your family's”/ “ your”/“NH name possessive plus” “and his family's”/“NH name possessive plus” “and her family”/“NH name possessive plus “family's”

WCPR22 WC/PDB – Exclusion of Expenses from WC/PDB Periodic Payments

When we figure how much to reduce  (1)  benefits, we do not count certain medical, legal, or other expenses which were paid out of  (2)   (3)  payments. We excluded  (4)  when we figured  (5)  benefits.

Fill-ins:

(1) “your”/“your and your family's”/“your family's”/“NH name possessive”/“NH name possessive plus “and his family's”/“NH name possessive plus “and her family's”/“NH name possessive plus “family's”

(2) “your”/“her”/“his”

(3) “workers' compensation”/“public disability”/“workers' compensation and public disability”

(4) Actual amount of excludable expenses in format $$$$$.¢¢ *

(5) “your”/“your and your family's”/“your family's”/“NH name possessive”/“NH name possessive plus “and his family's”/“NH name possessive plus “and her family's”/“NH name possessive plus “family's” *

(*) indicates that the fill-in is manual

WCPR23 WC/PDB Offset Based Upon Lump Sum Proration – Method A

 (1)   (2)  received a lump-sum award of $  (3)  to settle  (4)   (5)  claim. A lump-sum award affects Social Security benefits in the same way that periodic payments do. We treat a lump-sum award as if it were paid on a weekly basis.

When we figured how much to reduce  (6)  benefits, we treated the lump sum as if  (7)  had been paid $  (8)  each week. We excluded $  (9)  for legal expenses, and $  (10)  for medical expenses. Based on these facts, we can pay  (11)  benefits for  (12)  through  (13)  . We will reduce  (14)  benefits beginning  (15)  . We will again pay full benefits beginning  (16)  .

Fill-ins:

(1) NH FN/“You”

(2) “have”/“has”

(3) Money amount in the format “$$$$$.¢¢”

(4) “your”/“her”/“his”

(5) “workers' compensation”/“public disability”/“workers' compensation and public disability”

(6) “your”/“your and your family's”/“your family's”/“NH name possessive”/“NH name possessive plus “and his family's”/“NH name possessive plus “and her family's”/“NH name possessive plus “family's”

(7) NH FN/“you”

(8) Money amount in the format “$$$$.¢¢”

(9) Attorney fee amount in the format “$$$$.¢¢”

(10) Amount of medical expenses in the format “$$$$.¢¢”

(11) “you”/“you and your family”/“your family”/“him and his family”/“her and her family”/“him”/“her”/“her family”/“his family”

(12) Month and year of no offset *

(13) Month and year of no offset *

(14) “your”/“your and your family's”/“your family's”/“his and his family's”/“her and her family's”/“his”/“her”/“her family's”/“his family's”

(15) Month and year of no offset *

(16) Month and year of no offset

WCPR24 WC/PDB – Offset Based Upon Lump-Sum Proration – Method B

(*) indicates that the fill-in is manual

 (1)   (2)  received a lump-sum award of $  (3)  to settle  (4)   (5)  claim. A lump-sum award affects Social Security benefits in the same way that periodic payments do. We treat a lump-sum award as if it were paid on a weekly basis.

When we figured how much to reduce  (6)  benefits, we treated the lump sum as if  (7)  had been paid $  (8)  each week. We excluded $  (9)  for legal expenses, medical and other related expenses. For this reason, we lowered the weekly rate from $  (10)  to $  (11)  . This means that we will send  (12)   (13)  benefits beginning  (14)  .  (15)   (16)  .

Fill-ins:

(1) NH FN/“You”

(3) Lump sum gross amount “$$$$$.¢¢”

(2) “have”/“has”

(4) “your”/“her”/”his”

(5) “workers' compensation”/“public disability”/“workers' compensation and public disability”

(6) “your”/“your and your family's”/“your family's”/“NH name possessive”/“NH name plus “and his family's”/“NH name plus “and her family's”/“NH name possessive “family's”

(7) NH FN/“you”

(8) Money amount “$$$$.¢¢”

(9) Total amount of excludable expenses “$$$$.¢¢”

(10) Money amount “$$$$.¢¢”

(11) Money amount “$$$$.¢¢”

(12) “you”/“you and your family”/“your family”/“her”/“him”/“his family”/“her family”/“him and his family”/“her and her family”

(13)” additional”/“partial”/“full” *

(14) Month and year *

(15) “We will pay full benefits beginning [15a]”/null

[15a] Month and year/null (Period is part of fill-in.)

(*) indicates that the fill-in is manual

(16) Lump Sum Ending Date in the format “March 1999”/Null

WCPR25 WC/PDB Offset Based Upon Lump-Sum Proration – Method C

 (1)   (2)  received a lump-sum award of $  (3)  to settle  (4)   (5)  claim. A lump-sum award affects Social Security benefits in the same way that periodic payments do. We treat a lump-sum award as if it were paid on a weekly basis.

When we figured how much to reduce  (6)  benefits, we excluded $  (7)  for legal, medical and other expenses. We treated the rest of the lump sum, $  (8)  , as if  (9)  had been paid $  (10)  per week. We will pay full benefits beginning  (11)  .

Fill-ins:

(1) NH FN/“You”

(2) “have”/“has”

(3) Lump sum gross amount in the format “$$$$$.¢¢”

(4) “your”/“her”/“his”

(5) “workers' compensation”/“public disability”/“workers' compensation and public disability”

(6) “your”/“your and your family's”/“your family's”/“NH name possessive”/“NH name possessive plus “and his family's”/“NH name possessive plus “and her family's”/“NH name possessive “family's”

(7) Sum of attorney and medical expenses in the format “$$$$$.¢¢”

(8) Lump sum which remains in the format “$$$$$.¢¢”

(9) “you”/“she”/“he”

(10) Money amount in the format “$$$$.¢¢”

(11) Lump sum prorated ending date plus one month (month and year full benefits payable) in the format “June 1999”

WCPR27 WC/PDB – Offset Based Upon Unverified Allegation

We may have to change the amount of  (1)  benefits when we receive proof of the amount of  (2)   (3)  payments.

Fill-ins:

(1) FN possessive/“your”

(2) NH name possessive/“his”/“her”/“your”

(3) “workers' compensation”/“public disability”/“workers' compensation and public disability”

WCP028 WC/PDB – Benefits Offset – Number Holder May File for Reduced RIB (NH Age 65 before 12/19/2015)

We may continue to reduce or withhold  (1)  disability benefits until  (2)  age 65. We must take this action because of  (3)   (4)  payments.  (5)  payments do not affect retirement benefits.  (6)  may be eligible for retirement benefits at age 62. To apply, please get in touch with us three months before  (7)  age 62.

Fill-ins:

(1) “your”/“your and your family's”/“ NH name possessive”/“your family's”/“NH name possessive “and his family's”/“NH name possessive “and her family's”/“NH name possessive plus “family's”

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

(3) “your”/”his”/”her”

(4) “workers' compensation”/“ workers' compensation and public disability benefit”/ public disability benefit”

(5) “workers' compensation”/“ workers' compensation and public disability benefit”/ public disability benefit”

(6) “You”/“He”/“She”

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

WCP029 WC/PDB - WC/PDB Claim Pending – Number Holder Only

If  (1)  workers' compensation or public disability benefit payments, we may have to reduce  (2)  Social Security benefits. At that time,  (3)  may have to pay back any Social Security benefits that  (4)  not due. Please let us know the decision on the claim right away.

Fill-ins:

(1) FN “receives”/“you receive”

(2) “your”/“his”/“her”

(3) “you”/“he”/“she”

(4) “you were”/“he was”/“she was”

WCPR31 WC/PDB –Number Holder Appealing WC/PDB –Number Holder and Auxiliary

We will not reduce  (1)  benefit, or the benefits of  (2)  family, because of  (3)  payments until a decision is made on the appeal of  (4)  claim. Please let us know when a final decision is made. At that time, we may collect any money that should not have been paid.

Fill-ins:

(1) NH FN possessive/“your”

(2) “your”/ “her”/ “his”

(3) “workers' compensation”/“public disability”/“workers' compensation and public disability”

(4) “your”/”her”/”his”

WCP032 WC/PDB –Reporting Responsibilities Involving Receipt of WC/PDB – Number Holder

Please let us know right away about any:

Changes in  (1)  workers' compensation or public disability benefit payments.

Lump-sum award(s)  (2)  .

Other payments  (3)  that increase or decrease  (4)  workers' compensation or public disability benefit payments

Fill-ins:

(1) FN/“your”

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

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

(4) “your”/”his”/”her”

WCP060 WC/PDB – Removal of Offset – Number Holder Attains FRA

Starting  (1)  , we will stop reducing  (2)  Social Security disability benefits because of  (3)   (4)  payments. We stop reducing disability benefits when  (5)  full retirement age.

Fill-ins:

(1) Month and year NH attains FRA in format “July 2012”

(2) NH name possessive/“your”

(3) “your”/”his”/”her”

(4) “workers' compensation”/“public disability benefit”/“workers' compensation and public disability benefit”

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

WCP061 WC/PDB – Benefits Offset – Number Holder May File for Reduced RIB

We will continue to reduce or withhold  (1)  disability benefits until  (2)  full retirement age in  (3)  . We must take this action because of  (4)   (5)  payments.  (6)   (7)  payments do not affect retirement benefits.  (8)  may be eligible for reduced retirement benefits at age 62. If  (9)  to apply for retirement benefits, please contact us three months before  (10)  age 62.

Fill-ins:

(1) “your”/“NH name possessive”/“your and your family's”/“ your family's”/“NH name possessive “and his family's”/“NH name possessive “and her family's”/“NH name possessive plus “family's”

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

(3) Month and year NH attains FRA in format “July 2012”

(4) “your”/”his”/”her”

(5) “workers' compensation”/“public disability benefit”/” workers' compensation and public disability benefit”

(6) “Your”/“His”/“Her”

(7) “workers' compensation”/“public disability benefit”/” workers' compensation and public disability benefit”

(8) “You”/”He”/”She”

(9) “you decide”/“he decides”/”she decides”

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

NL 00725.475 “WDS” UTIs – Work and Earnings Facility of Payment

WDS001 Work Deductions – No Readjustment

Because  (1)   (2)  not due benefits, benefits to other members of the household should be increased. However, we will pay  (3)  instead of increasing the benefits to other family members. Since this money is really due to other members of the household, it should be used only for their needs.

Fill-ins:

(1) SN/Beneficiary's full name/“you”

(2) “is”/“are”

(3) “you”/”her”/ “him”

WDS002 Benefits to other Family Members in 1/96

Because  (1)   (2)  not due benefits, benefits to other members of the household should be increased. However, for months before January 1996 we will pay  (3)  instead of increasing the benefits to other family members. Since this money is really due the other members of the household, it should be used only for their needs.

For benefits payable beginning January 1996, we can no longer pay you the increase due other family members. We must pay them directly because of a change in the law.

Fill-ins:

(1) “you”/Beneficiary's Name

(2) “are”/“is”

(3) “you”/“him”/“her”

WDS003 Benefit Increase to Non-Working Auxiliaries

We raised  (1)  monthly benefit amount beginning  (2)  because of the work and earnings of another entitled person[s].

Fill-ins:

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

(2) Date

NL 00725.480 “WDW” UTIs – Withdrawal

WDWC02 Caption

 (1)  Withdrawal Can Be Cancelled

Fill-in:

(1) SN

WDW006 How to Cancel a Withdrawal

If you change your mind and want to receive these benefits, you may cancel your withdrawal by filing a written request with us. You have up to 60 days after the date of this letter to ask for cancellation. After the 60 days are over, you have to file a new application if you want to receive these benefits. You will not lose any benefits if you cancel your withdrawal within the 60 days.

WDW012 Pre-Adjudicative Withdrawal Approval

We have approved your request to withdraw  (1)  claim for all Social Security  (2)  .

Fill-ins:

(1) FN possessive/“your”

(2)retirement benefits/disability benefits/spouse's benefits/benefits

NL 00725.485 “WEP” UTIs – Windfall Elimination Provision

WEP003 Windfall Elimination Provision is First Applied – Number Holder

We reduced  (1)  Social Security benefits starting  (2)  . This is the first month  (3)  received a pension based on work not covered by Social Security taxes. When  (4)  this type of pension, we may apply the Windfall Elimination Provision to  (5)  Social Security benefits. This changes the way we figure  (6)  benefit amount.  (7)  benefit amount is less than it would be if  (8)  not receiving the pension. To learn more about how non-covered pensions affect Social Security benefits, please see our factsheet titled “Windfall Elimination Provision.” You can get this factsheet at  (9) 

online. You can also call, write, or visit us to get the factsheet.

Fill-ins:

(1) “beneficiary's full name, possessive”/”your”

(2) date in format “Month CCYY”

(3) “you”/“he”/“she”

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

(5) “your”/”his”/”her”

(6) “your”/”his”/”her”

(7) “Your”/”His”/”Her”

(8) “you were”/“he was”/“she was”

(9) www.socialsecurity.gov/pubs/EN-05-10045.pdf

WEP004 Windfall Elimination Provision no Longer Applies – Number Holder

We changed  (1)  benefit amount starting  (2)  . The Windfall Elimination Provision no longer reduces  (3)  benefits. We stopped applying this provision because  (4)  :

  • Reached 30 years of substantial earnings covered by Social Security taxes, or

  • Stopped receiving a pension based on work not covered by Social Security taxes.

To learn more about how non-covered pensions affect Social Security benefits, please see our factsheet titled “Windfall Elimination Provision.” You can get this factsheet at  (5)  online. You can also call, write, or visit us to get the factsheet.

Fill-ins:

(1) “your”/ “beneficiary's full name, possessive”

(2) date in format “Month CCYY”

(3) “your”/”his”/”her”

(4) “you”/“he”/“she”

(5) www.socialsecurity.gov/pubs/EN-05-10045.pdf

NL 00725.490 “WFO” UTIs – Windfall Offset

WFO002 Benefits Withheld Pending SSI Offset Computation – Attorney Involved

We are holding  (1)  Social Security benefits for  (2)   (3)   (4)  . We may have to reduce these benefits if  (5)  received Supplemental Income [SSI] for this period. W