Item 1A (SSN)

Enter the social security number (SSN) of the primary beneficiary/recipient. In CDB or DWB cases, show the number holder's (NH) SSN. To the right of the SSN in title II claims, enter the beneficiary identification code (BIC) shown under the BIC caption on the latest award document in the claims folder for the disabled beneficiary,e.g., “A” for disabled title II NH.

Item 1B (Type of claim/case)

Check the appropriate Title II category:

1. 1. 

   DIB - disabled beneficiary (wage earner)

2. 2. 

   FZ - disability freeze (wage earner)

3. 3. 

   DWB - disabled widow/widower beneficiary

4. 4. 

   CDB - childhood disability beneficiary

5. 5. 

   ESRD - end-stage renal disease

Item 1C (Other entitlement)

Check as appropriate. In concurrent cases, check the box for Title XVI.

In multiple entitlement claims, check the Title II block if the determination involves entitlement on another earnings record (e.g., HA-CDB, HA-DWB, etc.). Enter the claim type and cross-reference SSN in Item 24 (Remarks), using the following format: DWB SSN 123-00-6789.

Item 2/3 (name of payee or disabled or blind individual/address)

The following information should be taken from the latest determination in file (right or left side), unless more recent information is known.

1. 1. 

   Block A - enter representative payee's name, if any, including the term “for,” “on behalf of,” or “guardian of.”

   NOTE: 

   If the claimant has a representative payee, see instructions for completing Item 29 below.

2. 2. 

   Block B - Enter the name of the disabled or blind individual. If the individual is a CDB or DWB, enter the wage earner's name in Item 3 of the SSA-833-U5.

3. 3. 

   Block C - Enter the mailing address of record for the recipient or the disabled/blind individual, or, if applicable, the representative payee.

   If the beneficiary filed on their own behalf and is deceased, line out the address entry and input “beneficiary/recipient deceased.”

Item 4 (Date of birth)

Enter the claimant’s date of birth in MM/DD/YY format.

Item 5 (Date disability began)

Use the date on the previous SSA-833 or original SSA-831.

Item 6 (DO/BO address)

Enter the address for the claimant’s servicing field office (FO).

Item 7 (DO/BO and DDS code)

Enter the three-digit code for the claimant’s servicing FO.

Item 8 (Adjudicative level)

Check the appropriate block (e.g., ALJ Hearing, Appeals Council, U.S. District Court). In remand cases, check all that apply.

Item 9 (Determination)

Always check the box next to Disability.

Item 9A (Continuance)

Check if the ALJ decided that the claimant is still disabled.

Item 9B (Cessation)

Check if the ALJ revised the previous disability cessation date, and enter the new cessation date specified in the decision in MM/YY format.

Item 9C (Termination)

If Item 9B is checked, this box must be checked and completed as well. The period of disability closes on the last day of the second month following the month of cessation.

Items 9D-H (Extended Period of Eligibility (EPE) months)

Check and complete these blocks if the ALJ decision specifies EPE suspense and resumption months.

If the information about suspense months in the ALJ decision is incomplete or unclear, refer the issue to the PC unit responsible for evaluating issues involving suspensions and terminations due to work and earnings.

Item 11 (Reason for cessation)

If the ALJ decided that the claimant’s disability ceased, enter the appropriate code from the list in DI 13095.105. These codes also apply to cases where benefits are suspended during an EPE.

Item 12 (Reason for continuance)

If the ALJ decided that claimant’s disability continues, enter the appropriate code from the lists in DI 13095.115. The medical listing number is completed only in medical determinations. Codes from these lists also apply to cases where benefits are reinstated during an EPE.

Item 20 (Why review was made)

Enter the appropriate code from DI 13095.135.

Item 21/22 (Primary and secondary diagnosis)

Use the 4-digit diagnosis code or codes and 2-digit body system code from the most recent SSA-831-U5, SSA-832-U5, or SSA-833-U5 in the file.

Item 23 (Diary)

Complete only in continuances. Use the diary code from the most recent SSA-831 or SSA-833 unless the ALJ specifies a different review date in the decision.

Item 24 (Remarks)

Enter the following remarks:

“This reverses the determination dated [date of prior SSA-833].”

“Decision of Administrative Law Judge [name of ALJ] on [date of Decision].”

If the claimant has an appointed representative, enter “Representative involved.” Include the primary representative’s name and address.

Include remarks regarding any other pertinent issues, including multiple entitlement and representative payee involvement.

Item 29 LTR/PAR no.

Enter C13 In ALJ and AC decisions. If the beneficiary is legally competent, the notice should be sent to their own mailing address even if a representative payee is involved.

Item 31 (SSA Representative)

The adjudicator will print their name and job title.

Item 32 (SSA Code)

Enter the 3-digit office code (e.g., PC7).

Item 33 (Date)

Enter the date the form is completed in MM/DD/YY format.

Item 34 (List number)

Cases that fit certain criteria are assigned a listing code. See GN 01040.100 for common listing codes.