TN 39 (09-24)
   
   
   
   
      BEN031 NOTICE TO N/H WHEN DISABILITY ESTABLISHED IN DIB/RIB CLAIMS NO RECAL PROCESSED (J87)
      
      
      (Requested)
      
      Caption: Your Benefits
      
      Since  (1)  now entitled to a higher monthly disability benefit, we are stopping  (2)  retirement benefits.
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: Surname is
            Choice 2: you are
         Fill-in (2) - Systems Generated
            
            
Choice 1: her
            Choice 2: his
            Choice 3: your
          
    
   
      BEN032 ADJUSTMENT IN RETROACTIVE BENEFITS IN FIRST/NEXT CHECK (M09)
      
      
      (Requested)
      
      Caption: Your Benefits
      
      In  (1)   (2)  payment,  (3)  will receive the difference between the benefits already paid and those now due.
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: Surname possessive
            Choice 2: Beneficiary Full name possessive
            Choice 3: your
         Fill-in (2) - Requested As A One Position Alpha Character
            
            
Choice 1: (A) first
            Choice 2: (B) next
         Fill-in (3) - Systems Generated
            
            
Choice 1: she
            Choice 2: he
            Choice 3: you
          
    
   
      BEN047 NO BENEFITS DUE BECAUSE OF WORK AND EARNINGS (M42)
      
      
      (Requested)
      
      Caption: Your Benefits
      
      Because of  (1)   (2)   (3)  , we  (4)  cannot pay  (5)  monthly benefits at this time.
      
      
      
      Fill-in values:
         
         Fill-in (1) - Requested As A One Position Alpha Character
            
            
Choice 1: (A) your
            Choice 2: (B) Number Holder's name (possessive)
            Choice 3: (C) Beneficiary's name (possessive)
         Fill-in (2) - Requested As A One Position Alpha Character
            
            
Choice 1: (A) current work
            Choice 2: (B) incorrect payment
            Choice 3: (C) past overpayment
         Fill-in (3) - Requested As A One Position Alpha Character
            
            
Choice 1: (A) and past due medical insurance premiums
            Choice 2: (B) null
         Fill-in (4) - Requested As A One Position Alpha Character
            
            
Choice 1: (A) still
            Choice 2: (B) null
         Fill-in (5) - Systems Generated
            
            
Choice 1: you
            Choice 2: them
          
    
   
      BEN050 SPECIAL PAYMENT PROVISION FOR CHILDHOOD DISABILITY BENEFICIARY, WIDOW, WIDOWER, MOTHER
         OR PARENT WHO IS TERMINATED FOR MARRIAGE OR RE MARRIAGE (T09)
      
      
      (Requested)
      
      Caption: Your Benefits
      
      We might still be able to pay  (1)  if  (2)  married a person who is receiving Social Security benefits. Please get in touch with
         us if this is true.
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: Beneficiary's Name
            Choice 2: You
         Fill-in (2) - Systems Generated
            
            
Choice 1: he
            Choice 2: she
            Choice 3: you
          
    
   
      BEN051 BENEFICIARY ENTITLED ON MORE THAN ONE ACCOUNT BENEFITS COMBINED INTO ONE CHECK (B16)
      
      
      (Requested)
      
      Caption: Your Benefits
      
      We will send  (1)  both benefits in one check each month under  (2)  own Social Security claim number.
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: Beneficiary's full name
            Choice 2: you
         Fill-in (2) - Systems Generated
            
            
Choice 1: your
            Choice 2: his
            Choice 3: her
          
    
   
      BEN052 BENEFICIARY ENTITLED TO BENEFITS ON MORE THAN ONE ACCOUNT EACH BENEFIT PAID SEPARATELY
         (B18)
      
      
      (Requested)
      
      Caption: Your Benefits
      
      We will send  (1)  separate checks each month under each Social Security claim number.
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: Beneficiary's full name
            Choice 2: you
          
    
   
      BEN053 DUAL ENTITLEMENT AWARD OF PRIMARY BENEFITS WHEN BENEFICIARY PREVIOUSLY AWARDED AS
         AN AUXILIARY (B15)
      
      
      CAUTION: Use BEN053 only on the primary (BIC A) record. If BEN053 is requested on
            the
            auxiliary record, the systems generated fill-ins cannot generate correctly, so a System
            Bad notice
            alert will result.
      
      (Requested)
      
      Caption: Your Benefits
      
      We are reducing  (1)  benefits as a  (2)  by the amount to which  (3)  entitled on  (4)  own Social Security record. This means  (5)  benefits will now be  (6)  as a  (7)  plus  (8)  on  (9)  own record.
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: your
            Choice 2: his
            Choice 3: her
         Fill-in (2) - Systems Generated
            
            
Choice 1: (A) wife
            Choice 2: (B) husband
            Choice 3: (C) widow
            Choice 4: (D) widower
            Choice 5: (E) mother
            Choice 6: (F) father
            Choice 7: (G) disabled widow
            Choice 8: (H) disabled widower
            Choice 9: (I) disabled divorced widow
            Choice 10: (J) disabled divorced widower
         Fill-in (3) - Systems Generated
            
            
Choice 1: you are
            Choice 2: he is
            Choice 3: she is
         Fill-in (4) - Systems Generated
            
            
Choice 1: your
            Choice 2: his
            Choice 3: her
         Fill-in (5) - Systems Generated
            
            
Choice 1: your
            Choice 2: his
            Choice 3: her
         Fill-in (6) - Systems Generated
            
            
Choice 1: Money Amount
         Fill-in (7) - Systems Generated
            
            
Choice 1: (A) wife
            Choice 2: (B) husband
            Choice 3: (C) widow
            Choice 4: (D) widower
            Choice 5: (E) mother
            Choice 6: (F) father
            Choice 7: (G) disabled widow
            Choice 8: (H) disabled widower
            Choice 9: (I) disabled divorced widow
            Choice 10: (J) disabled divorced widower
         Fill-in (8) - Systems Generated
            
            
Choice 1: Money Amount
         Fill-in (9) - Systems Generated
            
            
Choice 1: your
            Choice 2: his
            Choice 3: her
          
    
   
      BEN075 RECOMPUTATION PROVISION NOT PROPERLY APPLIED (A88)
      
      
      (Requested)
      
      Caption: Your Benefits
      
      We found that we owe  (1)  money because we had not given  (2)  credit for earnings  (3)  had after we first figured  (4)  benefit amount. We will send  (5)  a back payment for past months and increase  (6)  monthly benefit amount.
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: you
            Choice 2: Beneficiary's Name
         Fill-in (2) - Systems Generated
            
            
Choice 1: you
            Choice 2: him
            Choice 3: her
         Fill-in (3) - Systems Generated
            
            
Choice 1: you
            Choice 2: he
            Choice 3: she
         Fill-in (4) - Systems Generated
            
            
Choice 1: your
            Choice 2: his
            Choice 3: her
         Fill-in (5) - Systems Generated
            
            
Choice 1: you
            Choice 2: Beneficiary's Name
         Fill-in (6) - Systems Generated
            
            
Choice 1: your
            Choice 2: his
            Choice 3: her
          
    
   
      BEN076 NO BENEFITS PAYABLE FOR THE RETROACTIVE PERIOD (B25)
      
      
      (Requested)
      
      Caption: Your Benefits
      
      There is a limit on how much we can pay on each Social Security record. We have paid
         all benefits due for  (1)  .  (2)  not due any money for this period.
      
      
      
      Fill-in values:
         
         Fill-in (1) - Requested As A Date In Format In Format Shown Below
            
            
Choice 1: MM/CCYY to MM/CCYY
            Choice 2: MM/CCYY
         Fill-in (2) - Systems Generated
            
            
Choice 1: You are
            Choice 2: Beneficiary's Name is
          
    
   
      BEN077 202(J) (1) CLAIM - ODD AMOUNT PAYABLE FOR RETROACTIVE PERIOD (B26)
      
      
      (Requested)
      
      Caption: Your Benefits
      
      There is a limit on how much we can pay on each Social Security record. For  (1)  we have paid all but  (2)  . For this reason, we will pay  (3)  to  (4)  in the next check.
      
      
      
      Fill-in values:
         
         Fill-in (1) - Requested As A Date In Format In Format Shown Below
            
            
Choice 1: MM/CCYY to MM/CCYY
            Choice 2: MM/CCYY
         Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢
            
            
Choice 1: Amount
         Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢
            
            
Choice 1: Total amount due
         Fill-in (4) - Requested As A Alpha Character or Name
            
            
Choice 1: A=you
            Choice 2: Name (Name of Beneficiary)
          
    
   
      BEN078 W TO D CONVERSION HIGHER BENEFITS POSSIBLE ON OWN OR PRIOR SPOUSE'S RECORD (B34)
      
      
      (Requested)
      
      Caption: Other Social Security Benefits
      
       (1)  may be able to get a higher benefit on  (2)  own Social Security record. Also, if  (3)  married before,  (4)  may qualify for a higher benefit on the record of a prior spouse. If  (5)   (6)  may be able to get a higher benefit on  (7)  own or someone else's Social Security record, please contact us.
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: You
            Choice 2: Beneficiary's Name
         Fill-in (2) - Systems Generated
            
            
Choice 1: your
            Choice 2: his
            Choice 3: her
         Fill-in (3) - Systems Generated
            
            
Choice 1: you were
            Choice 2: he was
            Choice 3: she was
         Fill-in (4) - Systems Generated
            
            
Choice 1: you
            Choice 2: he
            Choice 3: she
         Fill-in (5) - Systems Generated
            
            
Choice 1: you think
            Choice 2: he thinks
            Choice 3: she thinks
         Fill-in (6) - Systems Generated
            
            
Choice 1: you
            Choice 2: he
            Choice 3: she
         Fill-in (7) - Systems Generated
            
            
Choice 1: your
            Choice 2: his
            Choice 3: her
          
    
   
      BEN079 PC JURISDICTION OF CLAIM WHERE INQUIRIES SHOULD BE FORWARDED (B38)
      
      
      (System Generated)
      
      Caption: If You Have Any Questions
      
      If  (1)  to write to the office that handles  (2)  case, the address is:
      
      
       (3) 
      
       (4) 
      
       (5) 
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: you need
            Choice 2: Beneficiary's Name needs
         Fill-in (2) - Systems Generated
            
            
Choice 1: your
            Choice 2: his
            Choice 3: her
            Choice 4: Beneficiary's name possessive
         Fill-in (3) - Systems Generated
            
            
PSC Address Line 1
            Fill in (4) - Systems Generated
            PSC Address Line 2
         Fill-in (4) Systems Generated
            
            
 PSC Address Line 2 
         Fill-in (5) - Systems Generated
            
            
PSC Address Line 3
          
    
   
      BEN080 NO PAYMENT AWARD ELECTED TO CONTINUE REDUCED RIB (B42)
      
      
      (Requested)
      
      Caption: Your Benefits
      
      We approved  (1)  application for disability benefits. However, we will not pay  (2)  these benefits because  (3)  chose retirement benefits instead.  (4)  family would have received less money if  (5)  chose disability benefits.
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: your
            Choice 2: Beneficiary's Name possessive
         Fill-in (2) - Systems Generated
            
            
Choice 1: you
            Choice 2: him
            Choice 3: her
         Fill-in (3) - Systems Generated
            
            
Choice 1: you
            Choice 2: he
            Choice 3: she
         Fill-in (4) - Systems Generated
            
            
Choice 1: Your
            Choice 2: His
            Choice 3: Her
         Fill-in (5) - Systems Generated
            
            
Choice 1: you
            Choice 2: he
            Choice 3: she
          
    
   
      BEN081 DIB NOT PAID RIB HIGHER (B44)
      
      
      (Requested)
      
      Caption: Your Benefits
      
      We considered  (1)  application for disability benefits. Although  (2)  eligible for disability benefits, we cannot pay  (3)  because  (4)  already receiving higher retirement benefits.
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: your
            Choice 2: Beneficiary's Name possessive
         Fill-in (2) Systems Generated
            
            
Choice 1: you are
            Choice 2: he is
            Choice 3: she is
         Fill-in (3) - Systems Generated
            
            
Choice 1: you
            Choice 2: him
            Choice 3: her
         Fill-in (4) - Systems Generated
            
            
Choice 1: you are
            Choice 2: he is
            Choice 3: she is
          
    
   
      BEN082 CONVERSION BENEFIT INCREASE (NO RATES OR DATES) (B45)
      
      
      (System Generated)
      
      Caption: Your Benefits
      
       (1)  benefit amount includes the recent increase because of the change in the cost of
         living.
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: Your
            Choice 2: Beneficiary's name possessive
          
    
   
      BEN083 FUTURE ENTITLEMENT INFORMATION FOR TERMINATING YOUNG SPOUSE, B2, B1, etc. (B46)
      
      
      (Requested)
      
      Caption: Things To Remember
      
       (1)  may be eligible to get benefits again when  (2)  age 62. The people in any Social Security office will be glad to help  (3)  at that time.
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: You
            Choice 2: Beneficiary Name
         Fill-in (2) - Systems Generated
            
            
Choice 1: you are
            Choice 2: he is
            Choice 3: she is
         Fill-in (3) - Systems Generated
            
            
Choice 1: you
            Choice 3: her
          
    
   
      
      
      (Requested)
      
      Caption: What We Will Pay
      
       (1)  still due back payments for past months.  (2)  will receive this money over a period of months. We will start paying this money
         to  (3)  shortly, and will send  (4)  another letter explaining how we will pay  (5)  .
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: You are
            Choice 2: Beneficiary Name plus is
         Fill-in (2) - Systems Generated
            
            
Choice 1: You
            Choice 2: He
            Choice 3: She
         Fill-in (3) - Systems Generated
            
            
Choice 1: you
            Choice 2: him
            Choice 3: her
         Fill-in (4) - Systems Generated
            
            
Choice 1: you
            Choice 2: him
            Choice 3: her
         Fill-in (5) - Systems Generated
            
            
Choice 1: you
            Choice 2: him
            Choice 3: her
          
    
   
      BEN085 SURVIVOR BENEFIT AWARD BASED ON MBR FROM ODO (B54)
      
      
      (Requested)
      
      Caption: The Basis For Our Decision
      
      We have not yet looked at the facts about  (1)  case which are in an earlier file. We have requested this file from another office.
         However, because we do not want to hold up  (2)  checks while we get the file, we figured  (3)  benefits using the other facts we had. We will review  (4)  case after we get the file, and let  (5)  know if we need to make any changes.
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: your
            Choice 2: Beneficiary's Name possessive
         Fill-in (2) - Systems Generated
            
            
Choice 1: your
            Choice 2: his
            Choice 3: her
         Fill-in (3) - Systems Generated
            
            
Choice 1: your
            Choice 2: his
            Choice 3: her
         Fill-in (4) - Systems Generated
            
            
Choice 1: your
            Choice 2: his
            Choice 3: her
         Fill-in (5) - Systems Generated
            
            
Choice 1: you
            Choice 2: him
            Choice 3: her
          
    
   
      BEN086 GOVERNMENT PENSION FULL OFFSET GP ELIGIBILITY AFTER JUNE 30, 1983 (B69)
      
      
      (Requested)
      
      Caption: Your Benefits
      
      We reduce Social Security benefits paid to  (1)  if they also receive a government pension based on their own work. We reduce benefits
         by two-thirds of the amount of the pension.  (2)  benefit is less than two-thirds of the amount of the pension. For this reason, we
         cannot pay  (3)  .
      
      
      
      Fill-in values:
         
         Fill-in (1) - Requested As A One Position Alpha Character
            
            
Choice 1: (A) husbands or wives
            Choice 2: (B) widows or widowers
         Fill-in (2) - Systems Generated
            
            
Choice 1: Your
            Choice 2: Beneficiary's name possessive
         Fill-in (3) - Systems Generated
            
            
Choice 1: you
            Choice 2: him
            Choice 3: her
          
    
   
      BEN087 ALLEGED MISINFORMATION NOT UPHELD (B74)
      
      
      (Requested)
      
      Caption: Your Benefits
      
       (1)  filed  (2)  application for benefits on  (3)  .  (4)  said  (5)  did not file earlier because we gave misinformation on  (6)  . We can give  (7)  an earlier filing date if:
      
      
      
         - 
            
               • 
                   (8)  did not file for these benefits before  (9)  because we misinformed  (10)  about  (11)  eligibility for these benefits, or the person who acted for  (12)  about  (13)  eligibility for these benefits, and
                   
 
 
- 
            
               • 
                   (14)  did not get benefits  (15)  could have
                   
 
 
We looked at the facts and found that we did not misinform  (16)  about  (17)  eligibility for these benefits. Therefore, we're sorry, but  (18)  cannot get an earlier filing date.
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: You
            Choice 2: Beneficiary's Name
         Fill-in (2) - Systems Generated
            
            
Choice 1: your
            Choice 2: his
            Choice 3: her
            Choice 4: Beneficiary's Name possessive
         Fill-in (3) - Requested As A Date In Format Shown Below
            
            
Choice 1: MM/DD/CCYY (date application was filed)
         Fill-in (4) - Systems Generated
            
            
Choice 1: You
            Choice 2: He
            Choice 3: She
         Fill-in (5) - Systems Generated
            
            
Choice 1: you
            Choice 2: he
         Fill-in (6) - Requested As A Date In Format Shown Below
            
            
Choice 1: MM/DD/CCYY (date alleged misinformation was given)
         Fill-in (7) - Systems Generated
            
            
Choice 1: you
            Choice 2: him
            Choice 3: her
         Fill-in (8) - Systems Generated
            
            
Choice 1: you
            Choice 2: he
            Choice 3: she
         Fill-in (9) - Systems Generated (same as Fill -in 3)
            
            
Choice 1: MM/DD/CCYY (date application was filed)
         Fill-in (10) - Systems Generated
            
            
Choice 1: you
            Choice 2: him
            Choice 3: her
         Fill-in (11) - Systems Generated
            
            
Choice 1: your
            Choice 2: his
            Choice 3: her
         Fill-in (12) - Systems Generated
            
            
Choice 1: you
            Choice 2: him
            Choice 3: her
         Fill-in (13) - Systems Generated
            
            
Choice 1: your
            Choice 2: his
         Fill-in (14) - Systems Generated
            
            
Choice 1: you
            Choice 2: he
            Choice 3: she
         Fill-in (15) - Systems Generated
            
            
Choice 1: you
            Choice 2: he
            Choice 3: she
         Fill-in (16) - Systems Generated
            
            
Choice 1: you
            Choice 2: the person who acted for you
         Fill-in (17) - Systems Generated
            
            
Choice 1: your
            Choice 2: his
            Choice 3: her
         Fill-in (18) - Systems Generated
            
            
Choice 1: you
            Choice 2: he
            Choice 3: she
          
    
   
      BEN088 RIGHTS AND RESPONSIBILITIES DIB (G33)
      
      
      (System Generated)
      
      Caption: Your Responsibilities
      
      The decisions we made on  (1)  claim are based on information  (2)  gave us. If this information changes, it could affect  (3)  benefits. For this reason, it is important that  (4)  changes to us right away. We have enclosed a pamphlet, “What You Need To Know When You Get Social Security
         Disability Benefits”. It will tell  (5)  what must be reported and how to report. Be sure to read the parts of the pamphlet
         which explain what to do if  (6)  to work or if  (7)  health improves.
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: your
            Choice 2: Beneficiary's Name possessive
         Fill-in (2) - Systems Generated
            
            
Choice 1: you
            Choice 2: he
            Choice 3: she
         Fill-in (3) - Systems Generated
            
            
Choice 1: your
            Choice 2: his
            Choice 3: her
         Fill-in (4) - Systems Generated
            
            
Choice 1: you report
            Choice 2: he reports
            Choice 3: she reports
         Fill-in (5) - Systems Generated
            
            
Choice 1: you
            Choice 2: him
            Choice 3: her
         Fill-in (6) - Systems Generated
            
            
Choice 1: you go
            Choice 2: he goes
            Choice 3: she goes
         Fill-in (7) - Systems Generated
            
            
Choice 1: your
            Choice 2: his
            Choice 3: her
          
    
   
      BEN089 INTRODUCTORY STATEMENT DUAL ENTITLEMENT AWARD AUXILIARY/SURVIVOR PRIMARY BENEFICIARY
         IN PAY STATUS (G40)
      
      
      (Requested)
      
      Caption:
      
      We are writing to let  (1)  know that  (2)  entitled to monthly  (3)  benefits on the record of  (4)  beginning  (5)  .
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: you
            Choice 2: Beneficiary name
         Fill-in (2) - Systems Generated
            
            
Choice 1: you are
            Choice 2: he is
            Choice 3: she is
         Fill-in (3) - Requested As A One Position Alpha Character
            
            
Choice 1: (A) wife's
            Choice 2: (B) husband's
            Choice 3: (C) widow's
            Choice 4: (D) widower's
            Choice 5: (E) disabled widow's
            Choice 6: (F) disabled widower's
            Choice 7: (G) child's
            Choice 8: (H) mother's
            Choice 9: (I) father's
         Fill-in (4) Requested
            
            
Choice 1: Number holder's name
         Fill-in (5) Requested As A Date In Format Shown Below
            
            
Choice 1: Show the Beneficiary's date of entitlement on the other record in
               MM/CCYY format
            
          
    
   
      BEN090 REPLACEMENT NOTICE (M21)
      
      
      (Requested)
      
      Caption: None
      
      This letter replaces our previous letter (1).
      
      
      Fill-in values:
         
         Fill-in (1) Requested as a Date in the format shown below or Alpha character
            
            
Choice 1: (A) = Null
            Choice 2: dated in format MM/DD/CCYY
          
    
   
      BEN100 ACCRUED AMOUNT PAID IN INSTALLMENTS (B24)
      
      
      (Requested)
      
      Caption: Your Benefits
      
      A payment of  (1)  is due from  (2)  through  (3)  .  (4)  will receive this money over a period of months. We will send  (5)   (6)  more each month as part of the regular check  (7)  . We will start paying the extra money with the check  (8)  on  (9)  .
      
      
      
      Fill-in values:
         
         Fill-in (1) - Requested As A Money Amount In Format $$$$$.¢¢
            
            
Total amount due
         Fill-in (2) - Requested As A Date In Format Shown Below
            
            
Choice 1: MM/CCYY
         Fill-in (3) - Requested As A Date In Format Shown Below
            
            
Choice 1: MM/CCYY
         Fill-in (4) - Systems Generated
            
            
Choice 1: You
            Choice 2: He
            Choice 3: She
         Fill-in (5) - Systems Generated
            
            
Choice 1: you
            Choice 2: him
            Choice 3: her
         Fill-in (6) Requested As A Money Amount In Format $$$$$.¢¢
            
            
Choice 1: Amount of installment
         Fill-in (7) - Systems Generated
            
            
Choice 1: you already receive
            Choice 2: he already receives
            Choice 3: she already receives
         Fill-in (8) Choice 1: you receive
            
            
Choice 2: he receives
            Choice 3: she receives
         Fill-in (9) - Requested As A Date In Format Shown Below
            
            
Choice 1: Date in MM/DD/CCYY
          
    
   
      
      
      (System Generated)
      
      Caption: None
      
       (1)  been selected to participate in the Benefit Offset National Demonstration (BOND)
         project.
      
      
      
      Fill-in values:
         
         Fill-in (1)
            
            
Choice 1: You have
            Choice 2: Beneficiary's Name has
          
    
   
      BEN102 PAYMENT POSSIBLE TO OTHER FAMILY MEMBERS WHEN PRIMARY BENEFICIARY IS IMPRISONED/CONFINED
         (G41)
      
      
      (Systems Generated)
      
      Caption: Your Benefits
      
      Even though  (1)  benefits will stop, we can pay other members of  (2)  family if they are entitled on  (3)  record.
      
      
      
      Fill-in values:
         
         Fill-in (1)
            
            
Choice 1: Beneficiary's Name possessive
            Choice 2: your
         Fill-in (2)
            
            
Choice 1: your
            Choice 2: his
            Choice 3: her
         Fill-in (3)
            
            
Choice 1: your
            Choice 2: his
            Choice 3: her
          
    
   
      BEN103 GOVERNMENT PENSION PARTIAL OFFSET GP ELIGIBILITY AFTER JUNE 30, 1983 (B68)
      
      
      (Requested)
      
      Caption: Your Benefits
      
      We reduce Social Security benefits paid to  (1)  if they also receive a government pension based on their own work. We reduce benefits
         by two-thirds of the amount of the pension. For this reason, we are reducing  (2)  benefits beginning  (3)  , by  (4)  .
      
      
      
      Fill-in values:
         
         Fill-in (1) Request as a one position alpha character
            
            
Choice 1: (A) husbands
            Choice 2: (B) wives
            Choice 3: (C) widows
            Choice 4: (D) widowers
         Fill-in (2) System Generated
            
            
Choice 1: your
            Choice 2: Beneficiary's name possessive
         Fill-in (3) Requested As A Date In Format Shown Below
            
            
Choice 1: MM/CCYY
         Fill-in (4) Requested As A Money Amount In Format $$$$$.¢¢
            
            
Amount of reduction
          
    
   
      BEN104 ONE OR MORE CHECKS WITHHELD (M17)
      
      
      (Requested)
      
      Caption: Your Benefits
      
      Therefore we are withholding  (1)   (2)   (3)  .
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: your
            Choice 2: her
            Choice 3: him
         Fill-in (2) - Requested As A One Position Alpha Character
            
            
Choice 1: (A) check
            Choice 2: (B) checks
         Fill-in (3) - Requested As A Date In Format Shown Below
            
            
Choice 1: for MM/CCYY
            Choice 2: for MM/CCYY and MM/CCYY
            Choice 3: for MM/CCYY through MM/CCYY
          
    
   
      BEN105 BOND NOTIFICATION OF ADJUSTMENT
      
      
      (Requested)
      
      Caption: None
      
      We may have let  (1)  know earlier that we would increase  (2)  benefits to  (3)  per month due to the rise in the cost of living. We have refigured  (4)  benefits based on  (5)  participation in the benefit offset national demonstration project (BOND). This notice
         corrects the calculation to apply the cost of living increase to  (6)  original benefit before the reduction for BOND earnings.  (7)  new monthly amount (before deductions) is  (8)  .
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: you
            Choice 2: Name
         Fill-in (2) - System Generated
            
            
Choice 1: your
            Choice 2: Name possessive
         Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢
            
            
Choice 1: Amount (BRI/MBR incorrect monthly benefit amount)
         Fill-in (4) - Systems Generated
            
            
Choice 1: your
            Choice 2: Name possessive
         Fill-in (5) - Systems Generated
            
            
Choice 1: your
            Choice 2: his
            Choice 3: her
         Fill-in (6) - Systems Generated
            
            
Choice 1: your
            Choice 2: his
            Choice 3: her
         Fill-in (7) - Systems Generated
            
            
Choice 1: Your
            Choice 2: Name possessive
         Fill-in (8) - Requested As A Money Amount In Format $$$$$.¢¢
            
            
Choice 1: Amount (new offset monthly benefit amount)
          
    
   
      BEN106 BOND – EOYR Adjustment
      
      
      (Requested)
      
      Caption: Your Benefits
      
      Based on  (1)  earnings of  (2)  for  (3)  we should have paid  (4) 
      
      Amount Date
      
       (5)   (6) 
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: your
            Choice 2: Name possessive
         Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢
            
            
Choice 1: Amount (End of year BOND amount)
         Fill-in (3) - Requested As A Date In Format Shown Below
            
            
Choice 1: CCYY
            Choice 2: CCYY and CCYY
         Fill-in (4) - Systems Generated
            
            
Choice 1: you
            Choice 2: him
            Choice 3: her
         Fill-in (5) - Requested As A Money Amount In Format $$$$$.¢¢
            
            
Choice 1: Amount (MBC in $$$$$.¢¢ format)
         Fill-in (6) - Requested As A Date In Format Shown Below
            
            
Choice 1: MM/CCYY
            Choice 2: MM/CCYY through MM/CCYY
          
    
   
      
      
      (Requested)
      
      Caption: Your Benefits
      
      This means we paid  (1)  correctly based on the evidence  (2)  provided for the reconciliation year.
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: you
            Choice 2: Name
         Fill-in (2) - Systems Generated
            
            
Choice 1: you
            Choice 2: he
            Choice 3: she
          
    
   
      BEN108 BOND EOYR Overpayment or Underpayment
      
      
      (Requested)
      
      Caption: Your Benefits
      
      This  (1)  resulted from the difference in the yearly amount that  (2)  estimated  (3)  would earn during  (4)  and the actual amount that  (5)  earned, during that year. We determined the  (6)  after we recalculated  (7)  offset amount based on  (8)  actual BOND countable earnings.
      
      
      
      Fill-in values:
         
         Fill-in (1) - Requested As A One Position Alpha Character
            
            
Choice 1: (A) overpayment
            Choice 2: (B) underpayment
         Fill-in (2) - Systems Generated
            
            
Choice 1: you
            Choice 2: Name
         Fill-in (3) - Systems Generated
            
            
Choice 1: you
            Choice 2: he
            Choice 3: she
         Fill-in (4) - Requested As A Date In Format Shown Below
            
            
Choice 1: Date (Recon year in CCYY format)
         Fill-in (5) - Systems Generated
            
            
Choice 1: you
            Choice 2: he
            Choice 3: she
         Fill-in (6) - Requested As A One Position Alpha Character (same as Fill-in 1)
            
            
Choice 1: (A) overpayment
            Choice 2: (B) underpayment
         Fill-in (7) - Systems Generated
            
            
Choice 1: your
            Choice 2: his
            Choice 3: her
         Fill-in (8) - Systems Generated
            
            
Choice 1: your
            Choice 2: his
            Choice 3: her
          
    
   
      BEN109 BOND – No Longer Eligible For BOND Project – Term Date
      
      
      (Requested)
      
      Caption: Your Benefits
      
       (1)  been a participant in the Benefit Offset National Demonstration (BOND) project. The
         special rules for the BOND project will no longer apply to  (2)  beginning  (3)  .  (4)  .
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: You have
            Choice 2: Name has
         Fill-in (2) - Systems Generated
            
            
Choice 1: you
            Choice 2: him
            Choice 3: her
         Fill-in (3) - Requested As A Date In Format Shown Below
            
            
Choice 1: MM/DD/CCYY
         Fill-in (4) - Requested As A One Position Alpha Character
            
            
Choice 1: (A) You asked to be withdrawn from the project. If you are
               receiving benefit payments based on disability, your payments may stop the first month
               you do
               substantial gainful work.
            
            Choice 2: (B) He asked to be withdrawn from the project. If he is receiving
               benefit payments based on disability, his payments may stop the first month he does
               substantial
               gainful work.
            
            Choice 3: (C) She asked to be withdrawn from the project. If she is
               receiving benefit payments based on disability, her payments may stop the first month
               she does
               substantial gainful work.
            
            Choice 4: (D) You are no longer eligible for the project, because you have
               not completed the trial work period by September 30, 2017.
            
            Choice 5: (E) He is no longer eligible for the project, because he has not
               completed the trial work period by September 30, 2017.
            
            Choice 6: (F) She is no longer eligible for the project, because she has
               not completed the trial work period by September 30, 2017.
            
            Choice 7: (G) null
          
    
   
      BEN110 BOND – No Longer Eligible For BOND Project - Explanation
      
      
      (Requested)
      
      Caption: Your Benefits
      
       (1)  no longer eligible for the project because  (2)   (3)  . If  (4)  receiving benefit payments based on disability,  (5)  payments may stop the first month  (6)  substantial gainful work.
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: You are
            Choice 2: Name is
         Fill-in (2) - Systems Generated
            
            
Choice 1: you have
            Choice 2: he has
            Choice 3: she has
         Fill-in (3) - Requested As A One Position Alpha Character
            
            
Choice 1: (A) had benefits terminated prior to the BOND start date of
               participation
            
            Choice 2: (B) participated in another demonstration project
               before
            
            Choice 3: (C) moved to a foreign country
            Choice 4: (D) received benefits paid by the railroad
            Choice 5: (E) elected to receive benefits not based on a
               disability
            
            Choice 6: (F) no longer met the BOND eligibility criteria
         Fill-in (4) - Systems Generated
            
            
Choice 1: you are
            Choice 2: he is
            Choice 3: she is
         Fill-in (5) - Systems Generated
            
            
Choice 1: your
            Choice 2: his
            Choice 3: her
         Fill-in (6) - Systems Generated
            
            
Choice 1: you do
            Choice 2: he does
            Choice 3: she does
          
    
   
      BEN111 BOND Participation End Date
      
      
      (Requested)
      
      Caption: Your Benefits
      
       (1)  participation period ends  (2)  . Payments may end with the month  (3)  substantial gainful work after  (4)  .
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: Your
            Choice 2: Name possessive
         Fill-in (2) - Requested As A Date In Format Shown Below
            
            
Choice 1: MM/CCYY
         Fill-in (3) - Systems Generated
            
            
Choice 1: you do
            Choice 2: he does
            Choice 3: she does
         Fill-in (4) - Requested As A Date In Format Shown Below
            
            
Choice 1: MM/CCYY
          
    
   
      BEN112 BOND Participation End Date SGA
      
      
      (Requested)
      
      Caption: Your Benefits
      
       (1)  participation period ends  (2)  . Since  (3)  not demonstrated an ability to perform work at a substantial gainful activity (SGA)
         level, payments may end in the second month following the month  (4)  an ability to perform work at an SGA level.
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: Your
            Choice 2: Name possessive
         Fill-in (2) - Requested As A Date In Format Shown Below
            
            
Choice 1: MM/CCYY
         Fill-in (3) - Systems Generated
            
            
Choice 1: you have
            Choice 2: he has
            Choice 3: she has
         Fill-in (4) - Systems Generated
            
            
Choice 1: you demonstrate
            Choice 2: he demonstrates
            Choice 3: she demonstrates
          
    
   
      BEN113 BOND Special Rules
      
      
      (Requested)
      
      Caption: What Happens When The Special Rules For BOND No Longer Apply
      
      The special rules for the BOND project will no longer apply to  (1)  after  (2)  participation period ends. If  (3)  benefit payments based on disability after that month,  (4)  payments will stop the first month  (5)  substantial gainful work.
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: you
            Choice 2: Name
         Fill-in (2) - Systems Generated
            
            
Choice 1: your
            Choice 2: his
            Choice 3: her
         Fill-in (3) - Systems Generated
            
            
Choice 1: you receive
            Choice 2: he receives
            Choice 3: she receives
         Fill-in (4) - Systems Generated
            
            
Choice 1: your
            Choice 2: his
            Choice 3: her
         Fill-in (5) - Systems Generated
            
            
Choice 1: you do
            Choice 2: he does
            Choice 3: she does
          
    
   
      BEN114 BOND Adjustment
      
      
      (Requested)
      
      Caption: Why We Cannot Pay You
      
      We cannot pay  (1)  benefits for  (2)  under the rules of the Benefit Offset National Demonstration (BOND) project. This
         is due to  (3)  work and earnings. This does not change any current benefits  (4)  .
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: you
            Choice 2: Name
         Fill-in (2) - Requested As A Date In Format Shown Below
            
            
Choice 1: MM/CCYY
            Choice 2: MM/CCYY through MM/CCYY
         Fill-in (3) - Requested As A Language
            
            
Choice 1: Name (BOND participant)
         Fill-in (4) - Systems Generated
            
            
Choice 1: you receive
            Choice 2: he receives
            Choice 3: she receives
          
    
   
      
      
      (Requested)
      
      Caption: None
      
       (1)  will soon receive a check for  (2)  . This check is for benefits due to  (3)  for  (4)  under the rules of the Benefit Offset National Demonstration (BOND) project.  (5)  due this check because of  (6)  work and earnings. This does not change any current benefits  (7)  .
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: You
            Choice 2: Name
         Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢
            
            
Choice 1: Amount (refund amount)
         Fill-in (3) - Systems Generated
            
            
Choice 1: you
            Choice 2: him
            Choice 3: her
         Fill-in (4) - Requested As A Date In Format Shown Below
            
            
Choice 1: MM/CCYY
            Choice 2: MM/CCYY through MM/CCYY
         Fill-in (5) - Systems Generated
            
            
Choice 1: You are
            Choice 2: Name is
         Fill-in (6) - Requested As A Language
            
            
Choice 1: Name (BOND participant)
         Fill-in (7) - Systems Generated
            
            
Choice 1: you receive
            Choice 2: he receives
            Choice 3: she receives
          
    
   
      BEN116 BOND Project Contact Information
      
      
      (Requested)
      
      Caption: Your Benefits
      
      If  (1)  working and  (2)  not given us an estimate of  (3)  expected yearly earnings, please contact Abt Associates immediately. We show their
         contact information under the heading, “If You Have Questions About
         the BOND Project”. If  (4)  not give us an estimate, we may pay  (5)  incorrect benefit payments.
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: you are
            Choice 2: Name is
         Fill-in (2) - Systems Generated
            
            
Choice 1: have
            Choice 2: has
         Fill-in (3) - Systems Generated
            
            
Choice 1: your
            Choice 2: his
            Choice 3: her
         Fill-in (4) - Systems Generated
            
            
Choice 1: you do
            Choice 2: he does
            Choice 3: she does
         Fill-in (5) - Systems Generated
            
            
Choice 1: you
            Choice 2: him
            Choice 3: her
          
    
   
      BEN117 BOND Informational (No Change)
      
      
      (Requested)
      
      Caption: None
      
      Thank you for giving us information about  (1)  earnings for last year.  (2)  asked us to determine if there has been a change in the amount of benefits payable
         to  (3)  under BOND because of this information. Based on this evidence we have determined
         that there is no change to  (4)  monthly benefit amount for this period. This decision does not change any benefits
          (5)  may be currently receiving.
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: your
            Choice 2: Name possessive
         Fill-in (2) - Systems Generated
            
            
Choice 1: You
            Choice 2: He
            Choice 3: She
         Fill-in (3) - Systems Generated
            
            
Choice 1: you
            Choice 2: him
            Choice 3: her
         Fill-in (4) - Systems Generated
            
            
Choice 1: your
            Choice 2: his
            Choice 3: her
         Fill-in (5) - Systems Generated
            
            
Choice 1: you
            Choice 2: he
            Choice 3: she
          
    
   
      BEN118 BOND Informational
      
      
      (Requested)
      
      Caption: Your Benefits
      
      Thank you for giving us information about  (1)  earnings for the last year.  (2)  asked us to determine if there has been a change in the amount of benefits payable
         to  (3)  under BOND because of this information.
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: your
            Choice 2: Name possessive
         Fill-in (2) - Systems Generated
            
            
Choice 1: You
            Choice 2: He
            Choice 3: She
         Fill-in (3) - Systems Generated
            
            
Choice 1: you
            Choice 2: him
            Choice 3: her
          
    
   
      BEN119 BOND Request/Decision
      
      
      (Requested)
      
      Caption: None
      
      We received a request  (1)  .
      
      
      
      Fill-in values:
         
         Fill-in (1) - Requested As A One Position Alpha Character
            
            
Choice 1: (A) for an explanation
            Choice 2: (B) that we not collect the overpayment
            Choice 3: (C) that we review our decision
            Choice 4: (D) that we review our decision and not collect the
               overpayment
            
            Choice 5: (E) that we withhold a different amount