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1A – Social Security Number
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Enter the Social Security Number (SSN) of the primary beneficiary/recipient. Show
the wage earner's SSN in childhood disability cases (CDB) and disabled widow benefits
(DWB) cases.
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Enter the Beneficiary Identification Code (BIC), shown under the BIC caption on the
latest award document, to the right of the SSN; e.g., “A” for a disabled wage earner.
Also enter any numerical suffix following a designated BIC; e.g., “C1” for a CDB.
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1B – Type of Claim/Case
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Complete the appropriate block.
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1C – Other Entitlement
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Complete the appropriate block. Complete the “Title XVI” block on concurrent Title
II/Title XVI determinations. Complete the “Title II” block if there is other Title
II involvement (e.g., DIB-CDB, DIB-DWB, etc.).
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2A – Name of Payee (If Any)
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Enter the representative payee's name, if any, including the term “for,” “on
behalf of,” or “guardian of.”
Reference: See item 29 below if there is a representative payee.
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2B – Name of Disabled or Blind Individual
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Enter the first name, middle initial, last name of the disabled or blind individual.
Print the first three letters of the surname in capital letters in the embedded block
(e.g., JOHnson).
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2C -Address
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Enter the latest mailing address for the disabled/blind individual, or, if applicable,
the representative payee. Always include the zip code.
Do not show the bank address if direct deposit is involved.
Line out the address entry and enter “beneficiary/recipient deceased” in any case
where the beneficiary/recipient filed on their own behalf and is deceased.
CAUTION: If the most current address is different from the one shown in the file, change the
address so that all of our records (MBR, SSR, etc.) have the correct address.
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3 - Wage Earner's Name
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Enter the name of the wage earner whose SSN appears in item 1A, if the disabled individual
is a CDB or DWB.
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4 -Date of Birth
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Enter a 6-digit figure (e.g., 01/03/59).
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5 -Date Disability Began
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Enter the date from item 15A or 28B of the latest approved SSA-831-U3 (Disability
Determination and Transmittal) in file. Query the date of disability onset (DDO) field
on the Master Beneficiary Record (MBR), to obtain the date disability began if the
SSA-831-U3 is not available see SM 00510.200.
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6 -FO Address
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Enter a complete field office (FO) address and zip code.
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7 -FO and DDS Code
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Enter the FO code only.
NOTE: The Disability Determination Service (DDS) code applies only to DDS jurisdiction cases.
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8 -Adjudicative Level
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Complete the appropriate block.
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9 -Determination Findings
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Always complete the disability block. Complete items 9A and B only if the case does
not involve a statutorily blind person.
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9A -Continues
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Complete in continuance cases.
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9B - Ceased
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Complete if disability ceased and enter the month, day and year of cessation.
In failure to cooperate (FTC) cases, disability ceases in the first month in which
the individual fails, without good cause, to do what SSA/DDS has requested and the
individual was aware of the requirement to cooperate and the repercussions of failing
to do so. For further information on failure to cooperate cessations, see DI 28075.005F.
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9C - Period of Disability Terminated at the Close of the Last Day of
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Complete to show termination of disability (MM/YY). Rationale: Enter the last day of the second month after the month in which cessation occurs,
e.g., ceased in 12/15/92; terminated 02/28/93.
Reference: For instructions governing Extended Period of Eligibility (EPE) cases, see DI 13010.210.
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9D - EPE Begin Month
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Complete to show the beginning month of an EPE (MM/YY). Enter the month immediately
following the month of completion of the Trial Work Period (TWP).
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9E - EPE Reinstatement Allowed
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Complete to show that EPE reinstatement is allowed. Enter the first non-SGA month
during the EPE (enter MM/YY) after a prior suspension for SGA.
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9F - EPE Reinstatement Denied
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Complete to show that EPE reinstatement is denied (MM/YY).
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9G - EPE Suspension after Reinstatement
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Complete to show that benefits are suspended after reinstatement. Enter the month
and year a reinstated beneficiary returns to SGA during an EPE (show MM/YY).
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9H - EPE Benefit Termination Month
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Complete to show the benefit termination month (BTM) for EPE cases.
Enter the first MM/YY for which disability benefits cannot be paid after EPE; i.e.,
the month after the month in which the EPE ends.
Reference: For further information on payment of benefits during the EPE, see DI 13010.210E.
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9I - 301 Case
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Do not complete.
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9J -Blindness
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Do not complete.
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10 - Basis For Determination
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Complete appropriate blocks A-D.
Explain in item 24, if “OTHER” is checked.
Reference: For information on impairment-related work expenses (IRWE), see DI 10520.001.
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11 - Reason for Cessation
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Enter both a 1 position (example: “M” for medical) and a 2-position reason for cessation
code (example: “14” for whereabouts unknown)
For a complete listing of Title II reason for cessation codes, see DI 13095.105.
First, choose the more specific 2-position code, and then change it to the more general
1-position code. If more than one code applies for either of the 2 types of cessation
codes, choose one code for each type.
Enter this 1-position code between “REASON FOR CESSATION” and “CODE”. Then, circle the 1-position code.
Finally, enter a 2-position code in the “CODE” block.
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12 - Reason For Continuance and Medical List No.
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Enter the reason for continuance code.
Reference: For Title II continuance codes, see DI 13095.115.
The medical listing number is completed only in medical determinations.
Reference: For medical listing code numbers, see DI 34001.001 and DI 34005.001.
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13 - Continuation Sheet
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Complete when a rationale is required. Use a SSA-4268-U4 form (Explanation of Determination)
as a continuation sheet in all cases (For instructions on rationale preparation, see
DI 28090.000).
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14 - Vocational Rule
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Do not complete.
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15 - Vocational Background
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No entry
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16 - Occupational Years
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No entry
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17 - Educational Years
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No entry
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18 - Special Use
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No entry required.
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19 - Vocational Rehabilitation Action
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Do not complete.
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20 - Why Review Was Made
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Enter the appropriate code from DI 13095.135.
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21 and 22 - Primary and Secondary Diagnosis
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Enter the primary diagnosis in item 21 and the secondary diagnosis in item 22.
Obtain this data from the most recent SSA-831-U3 or SSA-833 in the file. Or, you may
also look at the QMMD (Query/Modify Medical Data) screen in the disability control
file (DCF) to obtain this data.
Refer the case, and the completed SSA-833 and folder to ODIO-PSC-DPB (after all actions
are completed), if this information is not available.
Annotate the routing slip “Route to disability examiner for entry of diagnoses (Item
21 and 22) and codes.”
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23 - Diary
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Do not complete.
Refer the completed SSA-833 and folder to ODIO/ PSC-DPB after all actions are complete.
Annotate the routing slip “Route to disability examiner for appropriate diary (item
23).”
NOTE: This is only necessary when a manual diary needs to be established. This should
be rare. Most actions are either automatically controlled by the Disability Control
File (DCF), or entered in the DCF before the case clears. A diary is entered in the
DCF, as well.
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24 - Remarks
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Enter the SSN of a CDB or DWB in a cessation.
Enter any of the following remarks, if appropriate. More than one remark can be entered.
(The following list is not all-inclusive.)
“This revises determination approved (date of prior determination)” if the present
determination revises a previous determination. “See Revised Determination of (date
of revised determination)” on the prior determination.
A clarifying remark to explain any inconsistency.
Enter the claimant's attorney's complete name and address if the attorney has requested
a copy of the notice.
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24A and 24B - Multiple Impairments
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Do not complete these items.
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25 and 26 - Disability Examiner/Claims Representative and Date
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Line through the words “Disability Examiner” or “Claims Representative” in item 25.
Sign in item 25, and enter the date in item 26.
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27 and 28 Physician or Medical Specialist Signature and Date
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Do not complete these items.
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29 - Letter and or Paragraph Number
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Enter the appropriate letter or paragraph code.
Reference: For notice language, see NL 00701.003.
Enter the letter number, e.g., 1013 without the letter prefix (SSA-L).
Include the letter prefix for paragraphs, e.g., T22.
Send the notice to the mailing address of the legally competent beneficiary/recipient
who has a representative payee. Make sure you send a copy of the notice to the representative
payee. Show at the bottom of both notices “Copies Sent to (name of the individual
(s) that copies are being sent).”
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30 and 30A - Physician or Medical Specialist. Signature and Date
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Do not complete these items.
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31 Through 33 - SSA Representative, SSA Code and Date
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Do not complete these items.
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34 - List Number
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Enter a code if appropriate.
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35 - Folder Sent To
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If the case is not electronic, show where the folder is being routed, e.g., NEPSC-DPB.
If the case is electronic, eWork completes this for you.
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