TN 22 (12-17)
NL 00725.280 “INS” UTIs – Insured Status
INS010 Number Holder Not Insured
(1) did not work long enough under Social Security for (2) to receive benefits.
Work under Social Security is figured in credits. Please read the enclosed pamphlet,
“How You Earn Social Security Credits,” which explains how the credits are earned
and how many a person needs to receive benefits.
For (3) to qualify for benefits, (4) needed to have earned:
a total of (5) credits, or
at least 6 credits in the period beginning (6) .
(7) earned a total of only (8) credits and only (9) credits in the period beginning (10) . These figures are based on (11) (12) date of birth, (13) and (14) (15) date of death, (16) .
Fill-ins:
(1) NH's FN
(2) “you”/“her”/“him”
(3) “you”/SN/FN/First Name
(4) NH's FN
(5) QCR in format 40
(6) 36 months from NH's DOD and enter month and year of first month in the quarter
in the format May 1944
(7) “She/He”
(8) QCE in format 10
(9) total numeric value of credits earned for period determined in fill-in 6
(10) Same as fill-in 6
(11) “her”/“his””
(12) “corrected”/null
(13) NH birthdate in format July 10, 1999
(14) “her”/“his”
(15) “corrected”/null
(16) NH date of death in format July 24, 1999
INS011 Number Holder Uninsured Survivor Disallowance (D/F Only)
(1) did not work long enough under Social Security for (2) to receive benefits.
Work under Social Security is figured in credits. Please read the enclosed pamphlet,
“How You Earn Social Security Credits,” which explains how the credits are earned
and how many a person needs to receive benefits.
For (3) to qualify for benefits, (4) needed to have earned (5) credits. (6) earned (7) credits. These figures are based on (8) (9) date of birth, (10) and (11) (12) date of death, (13) .
Fill-ins:
(1) NH's FN
(2) “you”/“her”/“him”
(3) “you”/SN/FN/First Name
(4) NH's FN
(5) QCR in format 40
(6) “She”/“He”
(7) QCE in format 10
(8) “her”/“his”
(9) “corrected”/null
(10) NH's birth date in format July 10, 1999
(11) “her”/“his”
(12) “corrected”/null
(13) NH's date of death in format July 24, 1999
INS012 Claimant Uninsured for Medicare
(1) did not work long enough under Social Security to qualify for Medicare.
Work under Social Security is figured in credits. Please read the enclosed pamphlet,
“How You Earn Social Security Credits,” which explains how the credits are earned.
For (2) to qualify for Medicare, (3) needed to have earned (4) credits. (5) earned (6) credits. These figures are based on (7) (8) date of birth, (9) .
Fill-ins:
(1) NH's FN
(2) SN
(3) NH's SN
(4) required QC's in format 40
(5) She/He
(6) earned QC's in format 10
(7) NH's SN possessive
(8) correct/null
(9) NH's birth date in format mm/dd/yy.
INS014 Auxiliary (Life) Claim Disallowed – Number Holder Uninsured
(1) did not work long enough under Social Security for (2) to receive benefits.
Work under Social Security is figured in credits. Please read the enclosed pamphlet,
“How You Earn Social Security Credits,” which explains how the credits are earned
and how many a person needs to receive benefits.
For (3) to qualify for benefits, (4) needed to have earned (5) credits. (6) earned (7) credits. These figures are based on (8) (9) date of birth, (10) .
Fill-ins:
(1) NH's FN
(2) “you”/“her”/“him”
(3) “you”/beneficiary's SN/FN/First Name
(4) NH's FN
(5) QCR in format 40
(6) “She”/“He”
(7) QCE in format 10
(8) “her”/“his”
(9) “corrected”/null
(10) NH's date of birth
INS015 LSDP Disallowance – Number Holder Not Insured
(1) did not work long enough under Social Security for (2) to qualify for the lump sum death payment.
For (3) to qualify for the lump sum death payment, (4) needed to have earned:
a total of (5) credits, or
at least 6 credits in the period beginning (6) .
(7) earned a total of only (8) credits and only (9) credits in the period beginning (10) . These figures are based on (11) (12) date of birth, (13) and (14) (15) date of death, (16) .
Fill-ins:
(1) NH's FN
(2) “you”/FN
(3) “you”/FN
(4) NH's SN
(5) QCR in format 40
(6) Subtract 36 months from NH's DOD and enter first month and year of quarter
(7) “She”/“He”
(8) QCE in format
(9) Total numeric value of credits earned during period determined in fill-in (6)
(10) same as fill-in (6)
(11) “her”/“his”
(12) “corrected”/null
(13) NH birth date
(14) “her”/“his”
(15) “corrected”/null
(16) NH date of death
INS016 Number Holder Uninsured – Medicare (Individual Other Than Number Holder Filed)
(1) did not work long enough under Social Security for (2) to qualify for Medicare.
Work under Social Security is figured in credits. Please read the enclosed pamphlet,
“How You Earn Social Security Credits,” which explains how the credits are earned.
For (3) to qualify for Medicare, (4) needed to have earned a total of (5) credits.
(6) earned a total of (7) (8) and still needs (9) more. These figures are based on (10) date of birth, (11) .
Fill-ins:
(1) NH's FN
(2) “you”/FN
(3) “you”/“her”/“him”
(4) NH's SN
(5) quarters needed in the format “40”
(6) NH's SN
(7) quarters earned in the format “40”
(8) “credit”/“credits”
(9) additional quarters needed
(10) NH's SN possessive
(11) NH's date of birth
INS020 Expiration of Disability Insured Status
We consider (1) disabled under our rules, if (2) a medical condition that:
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keeps (3) from doing any type of substantial gainful work, and
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has lasted or is expected to last for at least 12 months in a row or result in death.
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(4) also must have earned enough credit for work under Social Security.
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The last date when (5) had enough credits is (6) . We did not find that (7) disabled before this date.
Please read the enclosed pamphlet, “How You Earn Credits,” which tells you how to
earn credits and how many credits (8) to get benefits.
Fill-ins:
(1) “you”/FN
(2) “you have”/“he has”/ “she has”
(3) ”you”/“him”/“her”
(4) “You”/FN
(5) “you”/“he”/“she”
(6) Date last insured in format MM, YYYY
(7) “you were”/“he was”/ “she was”
(8) “you need”/“he needs”/ “she needs”
INS021 Disallowance – Not Insured
(1) (2) not worked long enough under Social Security to receive benefits (3) .
Work under Social Security is figured in credits. Please read the enclosed pamphlet,
“How You Earn Social Security Credits,” which explains how the credits are earned
and how many a person needs to receive benefits.
To qualify for benefits, (4) (5) a total of (6) work credits. (7) (8) earned (9) credits, and still (10) (11) (12) more. These figures are based on (13) (14) (15) .
Fill-ins:
(1) “You”/NH SN
(2) “have”/“has”
(3) “on your own record”/“on her own record”/“on his own record”
(4) “you”/“she”/“he”
(5) “need”/“needs”
(6) required QCs
(7) “you”/“she”/“he”
(8) “have”/“has”
(9) earned QCs
(10) “need”/“needs”
(11) quarters still needed
(12) “credit”/“credits”
(13) “your”/NH's FN possessive
(14) “corrected date of birth”/“date of birth”/null
(15) NH's date of birth