TN 12 (08-23)
DI 28095.100 Stock Letters for Title II, Title XVI, and Concurrent (Title II and Title XVI) Claims
Continuances
When preparing a manual notice for Title II, Title XVI and concurrent Title II and
Title XVI continuances, use this chart:
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Notices and Fill-ins
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Add Suffix to the Notice *
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Type of Case
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Title II
SSA-L1013
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Title XVI
SSA-L1014
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Disability Continues--No Work Activity--No Medical Reexamination Scheduled (SSI and
Title II DIB, CDB and DWB Claims)
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Check Block None
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Fill-in (Disabled)
Check Block None
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“A”-“Z”-“C25”
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Disability Continues--No Work Activity--Medical Re-exam Scheduled (SSI and Title II
DIB and CDB Claims)
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Check Block 6
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Fill-in (Disabled) Check Block 6
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“A”-“Z”-“C25”
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Disability Continues--Trial Work Period Less Than 9 Months--Work Stopped--Medical
Re-exam Scheduled (SSI and Title II DIB and CDB Claims)
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Check Block 2, 6
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Fill-in (Disabled) Check Block 2, 6
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“A”-“Z”-“C25”
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Disability Continues--Trial Work Period Less Than 9 Months--Work Stopped--No Medical
Re-exam Scheduled (SSI and Title II DIB and CDB Claims)
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Check Block 2
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Fill-in (Disabled)
Check Block 2
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“A”-“Z”-“C25”
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Disability Continues--Trial Work Period Less Than 9 Months--Work Continuing--No Medical
Reexamination Scheduled (SSI and Title II DIB and CDB Claims)
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Check Block 3
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Fill-in (Disabled)
Check Block 3
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“A”-“Z”-“C25”
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Disability Continues--Trial Work Period Completed--Work Stopped--Medical Re-exam Scheduled
(SSI and Title II DIB, CDB Claims)
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Check Block 2, 6
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Fill-in (Disabled)
Check Block 2, 6
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“A”-“Z”-“C25”
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Disability Continues--Trial Work Period Completed--Work Stopped-No Medical Re-exam
Scheduled (SSI and Title II DIB and CDB Claims)
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Check Block 2
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Fill-in (Disabled)
Check Block 2
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“A”-“Z”-“C25”
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Disability Continues--Trial Work Period Completed--Currently Working (Work Not SGA)--Medical
Reexamination Scheduled (SSI and Title II DIB and CDB Claims)
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Check Block 4, 6
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Fill-in (Disabled)
Check Block 4, 6
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“A”-“Z”-“C25”
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Disability Continues--Trial Work Period Completed--Currently Working (Work Not SGA)--No
Medical Reexamination Scheduled (SSI and Title II DIB and CDB Claims)
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Check Block 4
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Fill-in (Disabled)
Check Block 4
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“A”-“Z”-“C25”
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Blindness Continues--Medical Reexamination Scheduled (SSI and Title II DIB, DWB, CDB
Claims)
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Check Block 6
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Fill-In (Blind)
Check Block 6
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“A”-“Z”-“C25”
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Blindness Continues--No Medical Reexamination Scheduled (SSI and Title II DIB, DWB,
CDB Claims)
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Check Block None
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Fill-In (Blind)
Check Block None
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“A”-“Z”-“C25”
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Blindness Ends - Disability Continues - Follow DI 28080.065 for additional language needed. (SSI and Title II DIB, DWB, CDB Claims)
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Check Block 6
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Fill-in (Disabled)
Check Block 6
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“A”-“Z”-“C25”
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Disability Continues--Not Entitled to a Trial Work Period--Currently Working (Work
Not SGA)--No Medical Re-exam Scheduled (Title II DIB, CDB, and DWB Claims)
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Check Block 5
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Fill-in (Disabled)
Check Block 5
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“A”-“Z”-“C25”
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Title XVI procedures and Title XVI-Title II notices
Legend of fill-ins for check blocks:
1 Check Block 6--No fill-ins.
Check Block 2--Number of trial work service months tallied. (Never indicate more than
nine months)
Check Block 3--Number of months worked in the trial work period, and months counting
toward the trial work period.
Check Blocks 4--Month and year of review at end of trial work period.
Check Blocks 5--Trial work period months.
*NOTE: Suffix “A”--Indicates a copy of the notice that will be sent to the representative
identified in the Remarks portion of the SSA-832.
Suffix “Z”--Indicates a copy of the notice that will be sent to the authorized organization
who requested a copy.
Suffix “C25”--Indicates the beneficiary or recipient requests the return of a document
that
they
submitted.