Refer to Form SSA-3428-U2 (Determination of Disallowance Coding Sheet) “Name and Address Information” field in block 2 for completing the name and address.

This notice requires two fill-ins:

1. 1. 

   date of birth of wage earner

2. 2. 

   age

The necessary fill-ins for this notice should be shown in the “Disallowance Notice Information” field in block 4. If the fill-ins are not shown, return the claim to the individual who initiated the action.

If additional paragraphs are required, they will be shown on Form SSA-3428-U2 or Form SSA-573.