SMIB TERMINATION REVERSAL PARAGRAPHS — COMPUTER GENERATED IF EFFECTIVE MONTH OF BUY-IN PRECEDES TERMINATION MONTH SHOWN AS “MT” FACTOR IN ITEM 7 OF SSA-101

Your entitlement to medical insurance coverage under Social Security is still in effect. The previous notice from us that your coverage has been terminated was incorrect.

E TO D CONVERSION AFFECTING OTHER SURVIVORS

Your benefits have been reduced in the month shown above because another beneficiary became entitled to additional benefits.

TO FORMER WIFE — CHILD NO LONGER ENTITLED

We can pay you no further benefits because your child is no longer entitled to benefits based on the Social Security record of your former husband.

TO FORMER WIFE — NO CHILD IN HER CARE — PAYMENT SUSPENDED

We are stopping your payments because you are no longer caring for your child who is entitled to benefits on your former husband's Social Security record. If the child returns to your care, contact any Social Security office for help in having your payments begin again.

CHANGE OF PAYEE — FORMER REPRESENTATIVE PAYEE AN INDIVIDUAL

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Any Social Security benefits which have been saved for the beneficiary should be returned to us to be sent to the new payee. Therefore, if you have saved any of these funds, please return them and any interest that may have accrued. The check or money order should be made payable to “Social Security Administration, Claim Number 1.” Also, please return any checks you receive for the beneficiary after this date.

Fill in:

1. 1. 

   Claim Number (include BIC)

CHANGE OF PAYEE — FORMER REPRESENTATIVE PAYEE AN AGENCY OR INSTITUTION

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Any Social Security benefits which have been conserved for the beneficiary should be returned to us unless you have arranged with us to dispose of the funds in another way. You may use a check or money order to send the funds, along with any interest that may have accrued, to “Social Security Administration, Claim Number 1.” Also, please return any checks you receive for the beneficiary after this date.

Fill in:

1. 1. 

   Claim Number (include BIC)

CURRENTLY SUSPENDED WITH SOME BENEFITS PAYABLE

Beginning 1, no further benefits can be paid until you submit proof that you have entered and remained in the United States for one full calendar month. Our records show you do not meet any of the conditions, described in the enclosed booklet, that would permit payment of benefits outside the United States.

Enclosure: SSA Pub. No. 05-10137

Fill in:

1. 1. 

   MM/YY

BENEFITS NOW PAYABLE WITH SOME MONTHS SUSPENDED

Since you have been back in the United States a full calendar month, your benefits will resume 1. Benefits could not be paid from 2 through 3 because you did not meet any of the conditions described in the enclosed booklet, which would permit payment of benefits outside the United States.

Enclosure: SSA Pub. No. 05-10137

Fill ins:

1. 1. 

   MM/YY

2. 2. 

   MM/YY

3. 3. 

   MM/YY

DATE OF BIRTH ESTABLISHED UNDER GN 00302.350 or GN 00302.360 BEFORE FOREIGN BIRTH OR BAPTISMAL RECORD RECEIVED

Your date of birth has been established on the basis of the evidence you submitted thus far. The birth (baptismal) record that you have requested will be used to verify that this date of birth is correct. If this record is not received in the near future, we will ask the State Department to check with the appropriate public (church) official to determine whether a record of your birth (baptism) is on file and to obtain a copy of this record for us. If this document indicates that you were born on a different date than that established for you, we will notify you.

We are sorry to learn of your loss. Please accept our sincere sympathy.

We cannot pay you the Social Security benefits that were due to 1. We can pay 2 benefits to 3 spouse, children, parents, or legal representative of the estate. We must pay the benefits in that order.

Fill ins:

1. 1. 

   Full name of deceased beneficiary

2. 2. 

   His/her

3. 3. 

   His/her

We are sorry to learn of your loss. Please accept our sincere sympathy.

We cannot pay you the Social Security benefits that were due to 1. We can pay 2 benefits to 3 spouse, children, parents, or legal representative of the estate. We must pay the benefits in that order. Someone else will receive the benefits.

Fill ins:

1. 1. 

   Full name of deceased beneficiary

2. 2. 

   His/her

3. 3. 

   His/her

We are sorry to learn of your loss. Please accept our sincere sympathy. We cannot pay you the Social Security benefits you requested on 1 account. Our records show 2 is not due any benefits.

Fill ins:

1. 1. 

   Full name of deceased beneficiary

2. 2. 

   He/she

U.S. FEDERAL INCOME TAX WITHHELD FROM UNDERPAYMENT PAID TO NONRESIDENT ALIEN

The total amount of the underpayment is $1. However, we have deducted a 15 percent U.S. Federal income tax from this amount. This is why your check is $2.

Fill ins:

1. 1. 

   Total amount of the underpayment

2. 2. 

   Amount of underpayment after deduction for Federal income tax

NOT THE LEGAL SPOUSE

We find that under the law of the State involved, you were not legally married to the worker at the time of death. This may affect your eligibility to monthly survivors payments at age 1.

Fill in:

1. 1. 

   60/62

WIFE UNDER 62 AND WIDOW UNDER 60 (50 IF DISABLED) WITH PAYEE — CHILD NO LONGER ENTITLED

We can pay 1 no further benefits because her child is no longer entitled to benefits on this Social Security record. She may again become entitled to benefits when she reaches age 2. At that time any Social Security office will give complete information and assist in completing the application.

Fill ins:

1. 1. 

   Name

2. 2. 

   62/60/50 if disabled

PROCEEDS OF CHECK FOR MONTH OF DEATH OR LATER AND OVERPAYMENT ACCRUED PRIOR TO DEATH WITHHELD FROM LS

We have withheld $1, the amount of the insured person's Social Security payment for 2 plus the amount by which the insured was overpaid prior to death. The insured was not entitled to the benefits for 3 because Social Security benefits end with the month before the month of death. An additional amount was withheld because the insured was not entitled to receive this amount since 4.

Fill ins:

1. 1. 

   Amount withheld

2. 2. 

   MM/YY

3. 3. 

   MM/YY

4. 4. 

   Reason insured not entitled to the additional amount

CHILD RECEIVING DIRECT PAYMENT — AGE 18 — TERMINATED

We can no longer pay benefits to you since you attained age 18 in 1, and are not disabled or attending school in terms of the Social Security law.

Fill in:

1. 1. 

   MM/YY (month attained age 18)

TO APPLICANT — PART OF LUMP SUM AUTHORIZED TO BE PAID FUNERAL HOME, PART PAID TO APPLICANT

A check for $1 is also being sent to you as your share of the lump-sum death payment.

Fill in:

1. 1. 

   Amount

AWARD AMENDED TO EXCLUDE DISABILITY PERIOD

Your benefit amount has been refigured and increased as a result of the period of disability established for you.

EXCLUSION OF DISABILITY PERIOD DOES NOT INCREASE BENEFIT

We are unable to change the amount of your benefit. Refiguring it to take into account your period of disability would not increase your benefit amount.

PRIMARY BENEFITS BASED ON TRANSITIONALLY INSURED STATUS

This award is based on a special insured status provision contained in the Social Security Act. If you earn 1 additional quarters of coverage, you may qualify for increased benefits under the regular insured status requirements. In addition, benefits may become payable to other members of your family. The enclosed leaflet explains how a person earns Social Security credits.

Enclosure: SSA-10072

Fill in:

1. 1. 

   Number of additional quarters of coverage needed

SSI OFFSET OVERPAYMENT — OFFSET PERIOD IS SAME AS RETROACTIVE (PMA) PERIOD

In 1 you received $2 in Social Security benefits for 3. In paying this amount, we failed to take into account the SSI payments you had already received for that same period. If your Social Security benefits had been paid on time each month instead of in a single payment, your SSI payments would have been reduced. The $4 in SSI payments you would not have received if your Social Security benefits had been paid on time should have been withheld from your back Social Security benefits.

Fill ins:

1. 1. 

   Month and year PMA check was paid

2. 2. 

   Amount of PMA check

3. 3. 

   Months included in offset period (e.g., March 1980, or March and April 1980 or, March through June 1980)

4. 4. 

   Overpayment amount

SSI OFFSET OVERPAYMENT — OFFSET PERIOD LESS THAN RETROACTIVE (PMA) PERIOD

In 1 you received $2 in Social Security benefits. This included $3 for 4. In including this amount we failed to take into account the SSI payments you had received for that same period.

If your Social Security benefits had been paid on time each month instead of in a single payment, your SSI payments would have been reduced. The $5 in SSI payments you would not have received if your Social Security benefits had been paid on time should have been withheld from your back Social Security benefits.

Fill ins:

1. 1. 

   Month and year PMA check was paid

2. 2. 

   Amount of PMA check

3. 3. 

   Portion of the PMA paid for months in offset period

4. 4. 

   Months included in offset period (e.g., March 1980, or March and April 1980, or March through June 1980)

5. 5. 

   Overpayment amount

ALL OR PART OF EMPLOYMENT CLAIM IS COVERED BY RRB

Pay received from 1 could not be included because employment with this company is not covered by the Social Security Act and information from the Railroad Retirement Board shows that you have at least 120 months for railroad service.

The Railroad Retirement Board, 844 Rush Street, Chicago, Illinois 60611, will soon tell you whether you are eligible for benefits under the Railroad Retirement Act.

Fill in:

1. 1. 

   Name and address of employer(s)

ALL OR PART OF SERVICES FOR A “CARRIER” ARE FOUND TO BE COVERED UNDER THE SOCIAL SECURITY ACT

This award includes wages of $ 1 from 2. We have found that 3 percent of the work was in employment covered by the Social Security Act.

Fill ins:

1. 1. 

   Amount of wages

2. 2. 

   Name and address of employer

3. 3. 

   Percent figure

FOOTNOTE ADDED TO RRB COPIES OF CERTIFICATE OR NOTICE WHEN CONFLICT EMPLOYER IS INVOLVED

Application received by the Social Security Administration at 1 on 2.

Fill ins:

1. 1. 

   Address of Field Office

2. 2. 

   MM/DD/YY (application date)

SELF-EMPLOYMENT NOT COVERED

Remuneration for 1 was not included as creditable earnings from self-employment because it was derived from 2.

Fill ins:

1. 1. 

   Taxable year(s)

2. 2. 

   Illustrative reasons for insertion in above paragraph:

   1. a. 

      The practice of the profession of doctor of medicine.

   2. b. 

      Services as a (minister) (member of a religious order) (Christian Science Practitioner) with respect to which a valid and timely certificate of election of coverage was not filed.

   3. c. 

      The conduct of an activity which does not constitute a trade or business covered by the Social Security Act.

AMOUNT OF SEI REDUCED

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Under the law, all ordinary and necessary expenses paid or incurred in carrying on a trade or business and a reasonable allowance for depreciation of property used in the trade or business must be deducted in computing net earnings from self-employment. The reported new earnings from self-employment for 1 were reduced to $ 2 because of allowable deductions which were not taken.

Fill ins:

1. 1. 

   Taxable year(s)

2. 2. 

   Amount

PREVIOUS ACTION REVISED UPON RECONSIDERATION — NOT PRIMARILY DUE TO ADDITIONAL EVIDENCE

This action resulted from our reconsideration of your claim and replaces our previous determination.

If you believe that the reconsideration determination is not correct, you may request a hearing before an Administrative Law Judge of the Office of Hearings and Appeals. If you want a hearing, you must request it not later than 60 days from the date you receive this notice. You should make your request through any Social Security office.

Option-1. Read the enclosed leaflet for a full explanation of your right to appeal.

Enclosure: Pub. No. 70-10281

PREVIOUS ACTION REVISED UPON RECONSIDERATION — PRIMARILY DUE TO ADDITIONAL EVIDENCE

This action is based upon the additional evidence submitted and replaces our previous determination.

If you believe that the reconsideration is not correct, you may request a hearing before an Administrative Law Judge of the Office of Hearings and Appeals. If you want a hearing, you must request it not later than 60 days from the date you receive this notice. You should make your request through any Social Security office.

Option-1. Read the enclosed leaflet for a full explanation of your right to appeal.

Enclosure: Pub. No. 70-10281

PREVIOUS ACTION REVISED UPON RECONSIDERATION (FOR RESIDENTS OTHER THAN U.S., GUAM, AMERICAN SAMOA, PHILIPPINES, CANADA, MEXICO, WESTERN SAMOA AND BRITISH VIRGIN ISLANDS)

(F)

This action resulted from our reconsideration of your claim and replaces our previous determination.

If you believe that the reconsideration determination is not correct, you may request a hearing before an Administrative Law Judge of the Bureau of Hearings and Appeals. However, since no provision has been made for hearings to be held outside the United States, you would have to come into the United States at your own expense; or, an Administrative Law Judge would review your claim and make a decision on the basis of evidence already received plus any additional written evidence you may submit. If you desire a hearing or review by an Administrative Law Judge, you must request it not later than 60 days from the date you receive this notice. Address your request to International Program Service Center, SSA, P.O. Box 17769, Baltimore, MD 21203, U.S.A. If additional evidence is available, you should submit it with your request.

PREVIOUS ACTION REVISED UPON RECONSIDERATION AFTER IMPLIED REQUEST (FOR RESIDENTS OTHER THAN U.S., GUAM, AMERICAN SAMOA, PHILIPPINES, CANADA, MEXICO, WESTERN SAMOA AND BRITISH VIRGIN ISLANDS)

(F)

This action is based upon the additional evidence submitted and replaces our previous determination. If you believe that the reconsideration determination is not correct, you may request a hearing before an Administrative Law Judge of the Bureau of Hearings and Appeals. However, since no provision has been made for hearings to be held outside the United States, you would have to come into the United States at your own expense; or, an Administrative Law Judge would review your claim and make a decision on the basis of evidence already received plus any additional written evidence you may submit. If you desire a hearing or review by an Administrative Law Judge, you must request it not later than 60 days from the date you receive this notice. Address your request to International Program Service Center, SSA, P.O. Box 17769, Baltimore, MD 21203, U.S.A. If additional evidence is available, you should submit it with your request.

PROGRAM SERVICE CENTER RECONSIDERS CASE REMANDED PRIOR TO A HEARING

HEARING PARAGRAPH FOR RECONSIDERED DISABILITY CASES

We hope this satisfactorily explains the reason for the determination in your case. If you believe that the reconsideration determination is not correct, you may request a hearing before an Administrative Law Judge of the Office of Hearings and Appeals. If you want a hearing, you must request it not later than 60 days from the date you receive this notice. You should make your request through any Social Security office. Read the enclosed leaflet for a full explanation of your right to appeal.

Enclosure: SSA-10281

HEARING PARAGRAPH USED IN RECONSIDERATION NOTICE WHERE CLAIM IS DENIED ON THE BASIS OF RES JUDICATA

If you believe the reconsideration determination on your present application is not correct, you may request a hearing before an Administrative Law Judge of the Office of Hearings and Appeals. The Administrative Law Judge may, however, dismiss the request for hearing if he finds that your new application presents the same issues, facts, and parties as your prior application, and that the same law, regulations, and ruling precedents apply. If you want to request a hearing, you must do so not later than 60 days from the date you receive this notice. You may make your request through any Social Security office. Please read the enclosed leaflet for a full explanation of your right to appeal.

Enclosure: SSA-10281

RECONSIDERATION PARAGRAPH DISABILITY CEASES PAYMENTS CONTINUE

RECONSIDERATION PARAGRAPH - DISABILITY CEASES PAYMENTS TERMINATE

If you are not satisfied with either our finding that your period of disability ended or that 1. You may request that your case be reexamined on either or both issues.

Fill ins:

1. 1. 

   Insert one of the following:

   1. a. 

      You are no longer in a vocational rehabilitation program

   2. b. 

      You are no longer actively participating in a vocational rehabilitation program

   3. c. 

      You are not eligible for continued payments even though you are in a vocational rehabilitation program

COURT ORDER PROVIDES FOR PAYMENT OF ATTORNEY FEES

The amount of $1 has been deducted from your past due benefits of $2 and is being paid directly to your attorney in accordance with the order of the court, under section 206(b)(1) of the Social Security Act, providing for direct payment of attorneys' fees in court cases.

Fill ins:

1. 1. 

   Amount withheld

2. 2. 

   Amount of past due benefits

NOTICE TO AUXILIARY LIVING APART THAT COURT ORDER DOES NOT PROVIDE FOR PAYMENT OF ATTORNEY FEE

Section 206(b)(1) of the Social Security Act provides that your (husband's) attorney may ask the court to approve a fee not to exceed 25 percent of past due benefits. The past due benefits are those which are payable through

1, the month before the month the court rendered its decision. Pending resolution by the court of the fee to be allowed, we are withholding the amount of $2 which represents 25 percent of the past due benefits of $3 payable to you (and your family). This is in addition to the amount already withheld from your (husband's) past due benefits about which he has been notified. Upon receipt of the court order setting the fee, you will be notified further about the disposition of the amount withheld. The amount of your first check includes payments through 4.

Fill ins:

1. 1. 

   MM/YY

2. 2. 

   Amount withheld

3. 3. 

   Amount of past due benefits

4. 4. 

   MM/YY

DIRECT PAYMENT OF ATTORNEY'S FEE AT THE TIME AWARD IS MADE TO CLAIMANT

We have deducted $1 from your past due benefits and this amount is being sent to your attorney as his authorized fee. Section 206(a) of the Social Security Act provides for direct payment of authorized fees to an attorney who represents you on a Social Security claim.

Fill in:

1. 1. 

   Amount deducted for attorney's fee

COMBINED NOTICE WHERE DIRECT PAYMENT OF ATTORNEY FEE IS MADE AT THE TIME AWARD IS MADE TO CLAIMANT

The amount of $1 has been deducted from past due benefits due you and your family and is being paid directly to the attorney of record as his authorized fee under Section 206(a) of the Social Security Act.

Fill in:

1. 1. 

   Amount deducted from attorney's fee

SEPARATE NOTICE TO AUXILIARY WHERE ATTORNEY FEE HAS NOT YET BEEN AUTHORIZED

Since an attorney represented the person on whose Social Security record your claim was filed, the attorney's services assisted all claimants on this account to become entitled to benefits. For this reason, we must withhold 25 percent of all past-due benefits, $1, toward payment of the attorney's fee. Section 206(a) of the Social Security Act requires an attorney to obtain authorization from the Social Security Administration before a fee may be charged for services. This section of the law also provides that up to 25 percent of the claimant's past-due benefits can be used toward the payment of such fee.

When the amount of the fee is determined, the authorized fee will be paid directly to the attorney from the withheld benefits. If the amount of the authorized fee is less that the total amount withheld from all beneficiaries, it will be paid proportionally from withheld benefits. Any of the amount withheld from your benefits not needed for payment of the authorized fee will be sent to you.

Fill in:

1. 1. 

   Total dollar amount representing 25 percent of past-due benefits for auxiliary(ies)

APPEALS PARAGRAPH — DISABILITY CEASES PAYMENTS — PAYMENTS CONTINUE

If you do not agree that your disability has ended you may ask for a hearing by the Office of Hearings and Appeals even though your payments are being continued because you are in a rehabilitation program. You must do this not later than 60 days from the date you receive this notice.

APPEALS PARAGRAPH — DISABILITY CEASES — PAYMENTS TERMINATE

If you do not agree that your period of disability ended on that 1. You may request a hearing by the Office of Hearings and Appeals on either or both issues.

Fill ins:

1. 1. 

   Insert one of the following:

   1. a. 

      You are no longer in a vocational rehabilitation program

   2. b. 

      You are no longer actively participating in a vocational rehabilitation program

   3. c. 

      You are not eligible for continued payments even though you are in a vocational rehabilitation program

ADDRESS PARAGRAPH FOR ALJ, ODO, PSC, OHA

Send any fee petition to:

*F1

*F2

*F3

*F4

*F5

*F6

Fill-ins:

*F1—*F6 Address lines: Name and address of ALJ, OHO, or other component with jurisdiction (i.e., ODO, PSC, etc.) 2 line minimum, 6 line maximum.

FEE PETITION PARAGRAPH FOR COURT CASES

APPLICANT NOT ENTITLED TO MONTHLY BENEFITS — WORKER NOT FULLY INSURED

You are not entitled to monthly benefits because the worker was not fully insured at the time of death. In this case, to be fully insured 1 calendar quarters of work under Social Security are needed. The person had credit for 2 calendar quarters of work. The enclosed leaflets explain how a person earns Social Security credits.

Enclosures: SSA-10072 and SSA-10058

Fill ins:

1. 1. 

   Number of calendar quarters needed

2. 2. 

   Number of calendar quarters individual had

TO HUSBAND OR WIDOWER — WE OR SE PERSON NOT FULLY AND CURRENTLY INSURED

You are not entitled to monthly benefits because your wife was not fully insured at the time she died.

To be fully insured she needed 1 calendar quarters of work. She had credit for 2. The enclosed leaflet explains how a person earns Social Security credits.

Enclosure: SSA-10072

Fill ins:

1. 1. 

   Number of quarters needed

2. 2. 

   Number of quarters individual had

NOT A (WIFE) (HUSBAND) UNDER THE ACT

You are not now entitled to monthly benefits because you do not meet a requirement of the Social Security law. The requirement is that you be the parent of a child of the insured person or have been married to the insured for a least 1 year before applying for benefits. You may become entitled to benefits when you have been married for 1 year, provided you then file another application.

SPOUSE NOT YET 62 AND NO CHILD IN HER CARE UNDER AGE 16 OR UNDER OR DISABLED

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You are not entitled to monthly benefits now because you are under age 62 and do not have in your care a child age 16 or under (or disabled) who is entitled to benefits on your spouse's Social Security record. You may be eligible when you reach age 62 and should apply again at that time.

SPOUSE, WIDOW, OR WIDOWER DOES NOT QUALIFY UNDER STATE LAW

The requirement under the law of 1 has not been met because 2.

Fill ins:

1. 1. 

   State

2. 2. 

   Illustrated reasons as possible inserts:

   1. a. 

      Your husband's/wife's prior marriage had not ended when you married him/her

   2. b. 

      State does not recognize common law marriages as valid

CHILD NOT LEGALLY OR EQUITABLY ADOPTED

We cannot pay child's benefits on your claim because a requirement of the Social Security law is not met. The requirements are that the child must be the child, adopted child, or stepchild of the insured worker. 1 does not meet any of these requirements because 2.

Fill ins:

1. 1. 

   Name of child

2. 2. 

   Reason

NOT A CHILD UNDER STATE LAW OR DEEMED MARRIAGE PROVISIONS

To qualify for child's benefits, 1 must (1) have the legal relationship of child of the insured individual for inheritance purposes under the laws of 2, or (2) the parents must have gone through a marriage ceremony which meets certain requirements.

Since neither requirement has been met, 3 does not qualify for benefits.

Fill ins:

1. 1. 

   Name of child

2. 2. 

   State

3. 3. 

   Name of child

CHILD NOT STEPCHILD FOR REQUIRED PERIOD — N/H ALIVE

We cannot pay a child's benefit on your claim because a requirement of the Social Security law is not met. That requirement, which applies to stepchildren, is that the parent-child relationship must have existed for at least 1 year before the application for benefits is filed.

CHILD NOT STEPCHILD FOR REQUIRED PERIOD BUT MAY QUALIFY LATER — N/H ALIVE

The child may become entitled to benefits beginning 1, if another application is filed at or after that time.

Fill in:

1. 1. 

   MM/YY

CHILD 18 OR OVER — NOT DISABLED OR A FULL-TIME STUDENT

We cannot pay a child's benefit on your claim because a requirement of the Social Security law is not met. The requirement is that the child be under age 18; or if 18 or over, be a full-time student in an elementary school, or be under a disability as defined by law, which began before age 22.

The full-time attendance requirement is not met because 1.

Fill ins:

1. 1. 

   Illustrated reasons as possible inserts:

   1. a. 

      Course of study does not last at least 13 school weeks.

   2. b. 

      Scheduled classroom attendance is at a rate of less than 20 hours a week.

   3. c. 

      (Name of school) does not consider ____ to be in full-time attendance according to its standards for day students.

   4. d. 

      The school you are attending does not provide elementary or secondary education as determined under State or local law.

CHILD PAID BY EMPLOYER WHILE ATTENDING SCHOOL

A child age 18 or over is not considered a full-time student under the law if the child is paid by his or her employer while attending an educational institution at the request of or as a requirement of the employer.

SCHOOL DOES NOT QUALIFY AS AN EDUCATIONAL INSTITUTION

Benefits are not payable in this case because 1, the school which you are attending, does not qualify as an educational institution under the law.

Fill in:

1. 1. 

   Name of school

CHILD NOT DEPENDENT UPON STEPMOTHER (RSI CASES ONLY)

We cannot pay a child's benefit on your claim because a requirement of the Social Security law is not met. The requirement is that the child be dependent upon the stepmother at the time of her death or at the time benefits are applied for. A child is considered dependent upon the stepmother if the child was living with or receiving at least one-half support from the stepmother.

CHILD NOT DEPENDENT UPON STEPMOTHER (DIB CASES ONLY)

We cannot pay child's benefits on your claim because a requirement of the Social Security law is not met. The requirement is that the child be dependent upon the stepmother at the beginning of her period of disability, at the time she became entitled to disability insurance benefits, or at the time the child's application was filed. A child is considered dependent upon a stepmother if at such time the stepmother was living with the child or contributing at least one-half the child's support.

CHILD NOT DEPENDENT ON STEPFATHER (RSI CASES ONLY)

We cannot pay benefits because the child does not meet a requirement of the Social Security law. That requirement is that the child must have been dependent upon the stepfather at the time of his death or at the time the child's application was filed. A child is considered dependent upon a stepfather if the child was living with or receiving at least one-half support from the stepfather.

WIDOW/WIDOWER UNDER 60 — NO CHILD “IN CARE” — CHILD ENTITLED TO BENEFITS

You are not entitled to benefits now because you do not meet a requirement of the Social Security law. That requirement, for a 1 under age 60, is to have in your care a child, age 16 or under or a disabled child, of your spouse who is entitled to a child's benefit. You should apply again if and when such a child is in your care and if you are not then married. The people in any Social Security office will give you complete information and help you apply at that time.

Fill in:

1. 1. 

   Widow/widower

IF THE WIDOW/WIDOWER MAY BECOME ENTITLED TO BENEFITS AT AGE 60, ADD THE FOLLOWING

You may become entitled to 1 benefits when you are 60 even if you do not have a child in your care.

Fill in:

1. 1. 

   Widow/widower

SURVIVING DIVORCED MOTHER NOT ENTITLED, CHILD REQUIREMENT NOT MET

We cannot pay you 1 insurance benefits because you do not meet a requirement of the Social Security law. That requirement is that you have a child, age 16 or under or a disabled child, of your former husband in your care who is entitled to a child's benefit on his Social Security record and who is your natural or legally adopted child.

Fill in:

1. 1. 

   Father's/mother's

MOTHER OR FATHER NOT MARRIED TO WAGE EARNER AT TIME OF DEATH

We cannot pay you 1 insurance benefits because you do not meet a requirement of the Social Security law. That requirement is that the 2 must have been married to the parent of an entitled child who is in the care of the claimant for 3 benefits. The marriage must have been in existence at the time of death.

Fill ins:

1. 1. 

   Mother's/father's

2. 2. 

   Mother/father

3. 3. 

   Mother's/father's

WIDOW OR WIDOWER MARRIED — NOT ENTITLED TO BENEFITS

We cannot pay you 1 insurance benefits because a requirement of the law has not been met. That requirement is that the 2 must not be married. Since you are married, your claim has been disallowed.

Fill ins:

1. 1. 

   Widow's/widower's

2. 2. 

   Widow/widower

INDEPENDENTLY ENTITLED DIVORCED SPOUSE - DISALLOWANCE

We cannot pay you benefits based on 1's record at this time because you have not been divorced from 2 for at least 2 continuous years.

You can get Social Security Benefits as a divorced spouse when you have been divorced for at least 2 continuous years or when 3 is entitled to receive benefits. When either of these things happen, you should apply for benefits again.

Fill ins:

1. 1. 

   Full name of wage earner

2. 2. 

   Him/her

3. 3. 

   Full name of wage earner

INDEPENDENTLY ENTITLED DIVORCED SPOUSE - DISABILITY CESSATION

You can get Social Security benefits once again as a divorced spouse when you have been divorced for at least 2 continuous years of if 1 is again entitled to receive benefits. When either of these things happen, you should apply for benefits.

Fill in:

1. 1. 

   Full name of wage earner

CLAIMANT REIMBURSED FOR PAYMENT OF BURIAL EXPENSES

You are not entitled to the lump-sum death payment because you 1 reimbursed for your payment of the burial expenses. Payment is prohibited by Social Security regulations in such cases unless the claimant is entitled to the lump-sum as the widow or widower of the deceased.

Fill in:

1. 1. 

   Have been/will be

PROOF OF SUPPORT FILED AFTER SECOND ANNIVERSARY OF WE'S DEATH, GOOD CAUSE NOT ESTABLISHED OR NOT APPLICABLE

We cannot pay you 1 benefits because you did not file proof of support within the time limit. That time limit is within 2 years after the death occurred. The time limit may be extended only if there is good cause for failure to file the proof within the initial 2-year period.

Fill in:

1. 1. 

   Parent's/widower's

LUMP-SUM PAYMENT HAS BEEN MADE ON BEHALF OF ESTATE AND CLAIMANT DOES NOT ALLEGE FACTS WHICH WOULD RENDER PAYMENT INCORRECT

The lump-sum death benefit cannot be paid to you because it has already been paid to a representative on behalf of the estate. 1 has agreed to divide the payment among the persons legally entitled to it.

Fill in:

1. 1. 

   He/she

CLAIMANT (OTHER THAN SPOUSE) DID NOT PAY BURIAL EXPENSES

You did not pay the burial expenses for which reimbursement may be made.

CLAIMANT — ALLEGED TO BE SPOUSE AND DID NOT PAY ANY BURIAL EXPENSES

You do not have the status as the worker's spouse as required by law and you did not pay any of the burial expenses for which reimbursement may be made.

CLAIMANT ALLEGED TO BE SPOUSE AND PAID BURIAL EXPENSES NOT IN PRIORITY

You do not have the status as the worker's spouse under the law and none of the lump sum remains after applying it to burial expenses higher in the order of priority under the law.

CLAIMANT PAID BURIAL EXPENSES BUT WAGE EARNER SURVIVED BY SPOUSE LIVING IN THE SAME HOUSEHOLD

The surviving spouse was living in the same household with the worker at the time of death.

WIDOW/WIDOWER — NOT LIVING IN THE SAME HOUSEHOLD — DID NOT PAY BURIAL EXPENSES

You and your 1 were not living in the same household when 2 died and you did not pay any part of 3 burial expenses. Therefore, you are not entitled to the lump-sum death payment.

Fill ins:

1. 1. 

   Husband/wife

2. 2. 

   He/she

3. 3. 

   His/her

SURVIVORS BENEFITS ESTABLISHED UNDER RAILROAD RETIREMENT ACT

You are not entitled to payment under the Social Security law because it appears that benefits based on this worker's record are payable under the Railroad Retirement Act.

“VETERAN” UNDER THE ACT — NOT INSURED WITH MILITARY SERVICE CREDITS AND FAILS TO MEET REQUIREMENTS OF SECTION 217(b)

No benefits are payable under the veteran's provisions of the Social Security law because 1.

Fill ins:

1. 1. 

   Insert one of the following:

   1. a. 

      The worker died while in active (military) (naval) service.

   2. b. 

      The Veterans Administration has determined that a pension or compensation is payable by reason of the veteran's death.

   3. c. 

      The worker died more than 3 years after the date of his separation from active duty.

DISALLOWANCE FOR MORE THAN ONE REASON BUT INSUFFICIENT PROOF IN FILE TO MAKE DECISION

In addition to meeting the above requirements, you will need to submit proof of 1 if you again file for benefits.

Fill in:

1. 1. 

   The claims authorizer will furnish reason

NO INSURED STATUS INCLUDING MILITARY SERVICE CREDITS UNDER SECTION 217(a), (e)

Military service credits under the veterans' provisions of the Social Security law were not enough to change this decision.

REQUEST FOR RECALCULATION MILITARY SERVICE — NO INCREASE

We have received your request for a recalculation of your benefit rate based on military service. After examining your record, we find that this service does not increase your benefit amount.

INSURED INDIVIDUAL DIED AFTER DEPORTATION

The lump-sum death payment cannot be paid since the insured person was deported from the United States. Under the law, no lump-sum can be paid on the Social Security record of any person who dies in or after the month that he has been deported.

WIFE, CHILD, OR HUSBAND DISALLOWED BECAUSE W/E NOT ENTITLED TO RIB OR DIB

No benefits may be paid to the wife, husband, or child unless the wage earner or self-employed person is entitled to retirement or disability insurance benefits.

DENIAL OF REQUESTS FOR WITHDRAWAL OF CLAIM — REQUESTED CONSENT STATEMENTS ABSENT

You filed a request for withdrawal of your claim after we had made a decision on it. Under these circumstances, we cannot approve your withdrawal unless we receive the consent of everyone whose entitlement to benefits would be cancelled by your withdrawal. Since everyone concerned has not given his consent, we must disapprove your request.

DENIAL OF REQUEST FOR WITHDRAWAL — REFUND NOT MADE

You filed your request for withdrawal after we had begun to send you payments. Therefore before your withdrawal can become effective you must repay all benefits to which you are not entitled. In our recent letter, we notified you that you must repay $1. Since you have not repaid this amount, we must disapprove your request for withdrawal.

Fill in:

1. 1. 

   Amount

WITHDRAWAL APPROVED, NEW AWARD MADE — NOTICE TO PERSON WHOSE ENTITLEMENT IS NULLIFIED

We have approved 1's request for withdrawal of 2 claim for 3 insurance benefits. This withdrawal cancels your (first) claim for 4 benefits. Therefore, please disregard the previous Social Security Award Certificate which we sent to you. You are now entitled to the benefit described on this award certificate.

Fill ins:

1. 1. 

   Name of insured individual

2. 2. 

   His/her

3. 3. 

   Retirement/disability (type of benefit)

4. 4. 

   Wife's/mother's/child's/husband's (type of benefit)

WITHDRAWAL APPROVED — NOTICE TO WIFE, HUSBAND OR CHILD WHOSE ENTITLEMENT IS NULLIFIED

You will no longer be paid Social Security benefits because 1 has withdrawn 2 claim. This withdrawal has the effect of cancelling your entitlement. 3 benefits may be paid on an insured person's earnings record during 2 lifetime only if the person 4 is also entitled to benefits.

Fill ins:

1. 1. 

   Name of insured person

2. 2. 

   His/her

3. 3. 

   Wife's/child's/husband's

4. 4. 

   Himself/herself

INSERT PARAGRAPH FOR FORM SSA-L250 (SSA-L850) WITHDRAWAL APPROVED AFTER AWARD

We had awarded you benefits based on the application you have now withdrawn. Because of the withdrawal, this award is not in effect.

INSERT PARAGRAPH FOR FORM SSA-L250 (SSA-L850 — WITHDRAWAL APPROVED BEFORE ADJUDICATION

This means that we will not determine your benefit right or make payment to you on the basis of the application you have withdrawn.

WIFE OR WIDOW — UNDER 72 — W/E TRANSITIONALLY INSURED

Your claim for 1 benefits has been denied because you were not 72 before 1969. According to the information we have, your birth date is 2. The Social Security law allows payment of such benefits at age 72 under a special insured status provision only if you reached that age before 1969.

Fill ins:

1. 1. 

   Wife's/widow's

2. 2. 

   MM/DD/YY (date of birth)

WIDOW AGE 72 OR OVER DISALLOWED — NO TRANSITIONAL INSURED STATUS — W/E ATTAINED 65 OR DIED BEFORE 1957

Your claim for widow's benefits on 1 record has been denied because he had not worked long enough under Social Security. To be insured he must have credit for at least 2 calendar quarters of work. He had credit for 3. The enclosed leaflet explains how a person earns Social Security credits.

Enclosure: SSA-10072

Fill ins:

1. 1. 

   Name of W/E

2. 2. 

   Number of required quarters

3. 3. 

   Number of quarters credited

REQUEST FOR CHANGE OF ADDRESS — CLAIMANT ENTITLED TO HOSPITAL INSURANCE BENEFITS BUT NOT MONTHLY BENEFITS

Although you will not now be receiving monthly payments and the information about payments on the other side of this certificate does not apply to you, you should notify any Social Security office if your mailing address changes.

DISALLOWANCE OF CLAIM FOR HOSPITAL INSURANCE — NOT AGE 65

Your claim for hospital insurance has been denied because you are not yet age 65. The proof you furnished shows that you were born 1. You should reapply for health insurance protection during the 3-month period before the month in which you reach 65. At that time, please contact any Social Security office which will be glad to help you apply.

Fill in:

1. 1. 

   MM/DD/YY (date of birth)

DISALLOWANCE OF CLAIM FOR HOSPITAL AND MEDICAL INSURANCE COVERAGE — NOT 65 — APPLICANT FILED UNDER DEEMED INSURED PROVISION

Your claim for hospital and medical insurance coverage had been denied, because according to the information we have, you are not yet age 65. On the basis of this information, your birth date is 1. You may apply again for these benefits as early as 3 months before you become 65. The people in any Social Security office will be glad to help you apply at that time.

Fill in:

1. 1. 

   MM/DD/YY (date of birth)

MEDICAL INSURANCE BENEFICIARY (“M” BIC) POTENTIAL ENTITLEMENT AS SPOUSE OF PREMIUM PAYER

If you should need hospital care in the future, you should get in touch with any Social Security office. You may be eligible at that time for hospital insurance under Medicare, based on your 1 record or you may enroll during any enrollment period and pay a monthly premium.

Fill in:

1. 1. 

   Husband's/wife's

NOT A RESIDENT OF U.S. — DEEMED INSURED

You are not entitled to health insurance protection. To qualify for health insurance, a person who is not entitled to a Social Security benefit or railroad annuity must be a resident of the United States. A resident of the United States is one who makes his home in one of the 50 States, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, or American Samoa.

NOT A U.S. CITIZEN AND DOES NOT MEET ALIEN RESIDENCY REQUIREMENT — DEEMED INSURED

You are not entitled to health insurance protection under the Social Security Act because you are not a United States citizen and have not resided in the U.S. for a required period of time. A person not entitled to a Social Security benefit or railroad retirement annuity must be a citizen or must have been admitted to the United States for permanent residence and have actually resided in the U.S. for 5 years immediately before the month he filed for health insurance.

COVERED OR POTENTIALLY COVERED UNDER THE FEDERAL EMPLOYEES HEALTH BENEFITS ACT OF 1959 — DEEMED INSURED

You are not entitled to premium-fee hospital insurance protection under the Social Security Act because you are covered, or could have been covered, under the Federal Employees Health Benefits Act of 1959. The law provides that a person who is not insured for Social Security benefits cannot qualify for premium-fee hospital insurance if he is covered by enrollment under the Federal Employees Health Benefits Act of 1959 as of February 16, 1965, or in the first month his application for hospital insurance is effective, or if he could have been so covered and was in Federal employment after February 15, 1965.

APPLIED BEFORE BEGINNING OF INITIAL ENROLLMENT PERIOD

You are not entitled to medical insurance because you applied prior to the start of your initial enrollment period. The period during which a person may first elect medical insurance runs for 7 months starting 3 months before the month the person becomes age 65 and ending 3 months after that month. If you wish this protection, you should reapply during the 3-month period before the month you become 65.

CHILD ADOPTED BY N/H'S SURVIVING SPOUSE — NOT DEPENDENT ON N/H AT THE TIME OF DEATH

We cannot pay child's benefits on your claim because a requirement of the Social Security law was not met. The requirement is that the insured individual had to institute proceedings to adopt the child before his death, and that at the time of death the child had to be living in the insured's household and not receiving contributions toward his support from someone other than the insured or spouse, or from any public or private welfare organization which furnished services or assistance for children.

SPECIAL OC'S REQUIREMENT FOR ENTITLEMENT TO HI UNDER DEEMED INSURED PROVISIONS — AGE 65 IN OR AFTER 1968

You are not entitled to premium-fee hospital insurance protection on your record because you have not worked long enough under Social Security. To qualify, you must have credit for at least 1 calendar quarters of work. Our records show that you now have 2. You should apply again if you earn the additional quarters you need. The enclosed leaflet explains how a person earns Social Security credits.

Enclosure: SSA-10072

Fill ins:

1. 1. 

   Number of required quarters

2. 2. 

   Number of acquired quarters

CLAIM DISALLOWED FOR NONMEDICAL REASONS — DISABILITY DETERMINATION UNNECESSARY

Since you do not meet the above requirement, we have not made a decision on whether or not you are disabled within the meaning of the Social Security law.

CHRONIC RENAL DISEASE DISALLOWANCE — OPENING PARAGRAPHS

This refers to your claim for entitlement to Medicare benefits on the basis of a kidney condition. The law provides Medicare coverage if it has been medically determined that a course of dialysis or a kidney transplant is the required treatment and the individual is undergoing regular dialysis or has received a kidney transplantation. In addition, to be entitled, the individual must either meet certain insured status (work) requirements under applicable provisions of The Social Security or Railroad Retirement Acts or be entitled to a monthly Social Security benefit or railroad annuity (or be the spouse or dependent child of a person who meets such insured status requirements or who is entitled to a monthly benefit).

You are not entitled to Medicare coverage under these provisions because (use fill-in A, A-B, or C if a transplant or dialysis is not involved or follow instruction D).

Fill ins:

1. A. 

   You do not meet the insured status (work) requirements under applicable provisions of the Social Security or Railroad Retirement Acts and are not entitled to monthly Social Security or railroad benefits. (Add (b) — if filing as spouse or dependent child).

2. B. 

   And your (spouse)(parents) also (do/does) not meet these requirements.

3. C. 

   The evidence in your case show that you are not receiving a regular course of dialysis treatment nor have you received a kidney transplant.

4. D. 

   (If relationship or dependency requirements are not met, use the applicable paragraphs in NL 00711.035, NL 00711.040, and NL 00711.045 with appropriate modification. The assistance of a claims authorizer should be obtained in these cases.)

5. E. 

   Under the law, you are responsible for furnishing evidence to support your claim. Although we requested additional evidence, you have not given it to us. Therefore, our determination is based on the evidence in your file. This evidence does not show that you meet the requirements for Medicare coverage based on chronic renal disease.

Enclosure: SSA Pub No. 05-10058

DISABILITY ESTABLISHED — HEALTH INSURANCE COVERAGE DATE BEGINS MORE THAN 2 MONTHS AFTER THE CURRENT OPERATING MONTH — HI/SMI BEGINS IN SAME MONTH

Your claim to establish eligibility for health insurance coverage under title XVIII of the Social Security Act, as a disabled individual, has also been approved. Your health insurance coverage begins in 1. A Health Insurance Identification Card will be mailed to you in or before that month.

Enclosure:  SSA Pub. No. 05-10153

Fill in:

1. 1. 

   MM/YY

MEDICARE TERMINATION — REVISED DATE OF ENTITLEMENT TO DISABILITY BENEFITS

The change in the date you became entitled to disability benefits has affected the date your Medicare coverage will begin.

Your Medicare coverage ends the last day of 1. You should not use the Medicare card we sent you earlier after this date. We will get in touch with you again shortly before you are eligible for Medicare to give you a chance to enroll.

Fill in:

1. 1. 

   MM/YY

CHILD NOT DISABLED BEFORE AGE 22 ATTAINED (AGE 22 OR OLDER)

We have determined that your condition was not disabling before age 22. In deciding this, we studied your records, including the medical evidence and considered your education and training in determining how your condition affects your ability to work.

CHILDHOOD DISABILITY — LAW PARAGRAPH

Childhood disability benefits may be paid to a person age 18 or older if the person has a disability which began before age 22 or within 84 months of the end of an earlier period of childhood disability. The condition, whether physical or mental, must be severe enough to keep the person from doing any substantial gainful work. We look at the person's age, education, and previous training when we decide whether he or she can work. In addition, the condition must have lasted or be expected to last for at least 12 months in a row.

CHILD NOT DISABLED THROUGH POINT OF DECISION (NOT YET AGE 22)

We have determined that your condition is not disabling. In deciding this, we studied your records, including the medical evidence, and considered your education and training.

CHILDHOOD DISABILITY — LAW PARAGRAPH — CLAIMANT NOT YET AGE 22

Childhood disability benefits may be paid to a person age 18 or over if the person has a disability which began before age 22.

The impairment, whether physical or mental, must be so severe that it prevents the person from performing any substantial gainful work. In addition, the condition must have lasted or be expected to last for a continuous period of at least 12 months.

If your condition should get worse before you reach age 22 and prevent you from doing substantial gainful work, you should write or call at any Social Security office about filing another disability claim.

NO CDB REENTITLEMENT — AOD AFTER END OF 7 YEARS AFTER PRIOR CESSATION

We have determined that you do not qualify for reentitlement to childhood disability benefits. Under the law, a person who was entitled to childhood disability benefits may become reentitled to such benefits if the person again becomes disabled within 7 years after prior entitlement to benefits terminated because disability ceased. In your case, your entitlement to child's benefits terminated on 1. Since you stated that you again became disabled on 2, which is after the end of the 7-year period, your claim for reentitlement cannot be approved.

Fill ins:

1. 1. 

   MM/YY

2. 2. 

   MM/YY

TITLE II MEDICAL CESSATION APPEALS LANGUAGE — ADVANCE NOTICE REQUIRED — SSI PAYMENTS BEING MADE

YOUR RIGHT TO APPEAL

If you think we are wrong, you have the right to ask for a hearing. If you ask for a hearing, we will review our decision. If we made a mistake, we will fix it. If you have any questions, get in touch with us. Please bring this notice with you if you come to a Social Security office.

You have 60 DAYS TO ASK FOR A HEARING after you get this notice. If you wait more than 60 days, you must have a good reason.

APPEAL IN 10 DAYS TO KEEP GETTING YOUR SAME PAYMENT

We will not change your payment if you ask for a hearing within 10 days after getting this notice. You will keep getting your same payment until we decide your case again. If you lose your appeal, you will be asked to pay this money back, although you will have the right to ask that you not be required to pay it back. If you win your appeal, any money you are due will be paid. A Social Security office can explain your rights and responsibilities to you in greater detail.

HOW TO ASK FOR A HEARING

TO ASK FOR A HEARING, YOU MUST MAKE A REQUEST IN WRITING. Be sure you tell us your name, Social Security number, and why you think we are wrong. If you cannot write to use, call our office or come in and someone will help you.

If you ask for a hearing, an administrative law judge will review your case. The judge will let you know where and when the hearing will be held.

At the hearing, the judge will explain all the facts in your case and all of the questions to be decided. The judge will also explain the law. Then, you can tell the judge why you thing we are wrong. You can give more facts to help prove you are right. You can also bring other people to help explain you case.

LEAD-IN PARAGRAPH

You were previously notified in our notice sent to you on 1 that the last disability check to which you are entitled is for the month of 2.

Fill ins:

1. 1. 

   Date of advance notice

2. 2. 

   Date of termination of benefits

RECONSIDERATION PARAGRAPH

Information regarding your reconsideration rights is shown on the back of this notice. However, since you were notified regarding the disability determination in our letter dated 1, any request for reconsideration of that determination must be made not later than 2. You may make your request through any Social Security office. If additional evidence is available, you should submit it with your request. Please read the enclosed leaflet for a full explanation of your right to question the determination made on your claim.

Enclosures: SSA Pub. No. 05-10058 and Envelope

Fill ins:

1. 1. 

   Date of advance notice

2. 2. 

   Date of advance notice plus 60 days

HEARING PARAGRAPH

The above determination resulted from the recent decision rendered on your claim at your request. If you believe that the reconsideration determination is incorrect, you may request a hearing before an administrative law judge of the Office of Hearings and Appeals. If you desire a hearing, you must request it not later than 1. You may make your request through any Social Security office.

Fill in:

1. 1. 

   Date of reconsideration notice plus 60 days

RIGHT TO FILE SUBSEQUENT APPLICATION

If you do not request a 1 of your case, you still have the right to file another application at any time.

Fill in:

1. 1. 

   Reconsideration/hearing

DIB — NOT QUALIFIED BEFORE FULL RETIREMENT AGE — SUBSTANTIAL GAINFUL WORK

A person who cannot continue in the usual line of work is not necessarily considered disabled under the law. Rather, the person must be unable to do substantial gainful work in any occupation. It has been determined that you first became unable to do any substantial gainful work on the date shown above.

DISABILILTY DENIAL — GENERAL CLOSEOUT PARAGRAPH

In addition, you are not entitled to any other benefits based on this application. If you have applied for other benefits, you will receive a separate notice when a decision is made on that claim.

DWB — LUMP SUM DEATH PAYMENT DENIAL — EOD NOT ON OR BEFORE THE FIRST DAY OF THE FIFTH MONTH PRECEDING WORKER'S MONTH OF DEATH

To get a lump sum death payment you must have been disabled on or before 1. We have decided that you were not disabled on or before that date. Our decision is based on a careful review of your medical records and statements. Attached is an explanation of how we decided your claim.

A widow or widower (age 50-60) may be considered disabled only if he or she has a physical or mental impairment that is so severe as to ordinarily prevent a person from working. The disability must have lasted or be expected to last for a continuous period of at least 12 months.

Fill in:

1. 1. 

   Month/day/year of the first day of the fifth month before the month the wage earner died

CDB — LUMP SUM DEATH PAYMENT DENIAL — EOD NOT ON OR BEFORE THE MONTH OF DEATH OF WORKER

To get a lump sum death payment 1 must have been disabled on or before 2. We have decided that 3 disabled on or before that date. Our decision is based on a careful review of 4 medical records, education, and training. Attached is an explanation of how we decided your claim.

Childhood disability can apply to a person age 18 or over who has a disability which began before age 22. The impairment, whether physical or mental, must be so severe that it prevents the person from performing any substantial gainful work. In addition, the condition must have lasted or be expected to last for a continuous period of at least 12 months.

Fill ins:

1. 1. 

   You/your child

2. 2. 

   Month/year of wage earner's death

3. 3. 

   You were not/your child was not

4. 4. 

   Your/your child's

GENERAL DESCRIPTION OF EARNINGS REQUIREMENT

A person whose disability began before age 24 meets the earnings requirement of the law if Social Security credits have been earned for 6 calendar quarters (1 1/2 years) of work during the 12 quarter (3 year) period ending with a quarter before age 24 in which the disability exists. A person whose disability began between the ages 24 and 31 meets the earnings requirement if Social Security credits have been earned for work in at least

one-half of the calendar quarters in the period beginning with the calendar quarter after age 21 and ending with a quarter before age 31 in which the disability exists. A person whose disability began at age 31 or later needs to meet two provisions of the earnings requirement: (1) The person needs credit for 20 calendar quarters (5 years) of work during a 40 quarter period (10 years) ending in or after a quarter in which disability exists, and (2) The person needs credit for one calendar quarter of work for each year after 1950 (or after reaching age 21, if that is later) up to the year the disability began. In this second instance, the credits do not have to have been earned during the past 10 years.

DESCRIPTION OF 6/12 TEST — DISABILITY BEFORE AGE 24

A person whose disability began before age 24 meets the earnings requirement if Social Security credits have been earned for 6 calendar quarters (1 1/2 years) of work during the 12 quarter (3 year) period ending with a quarter before age 24 in which the disability exists.

DESCRIPTION OF EARNINGS REQUIREMENT — DISABILITY BETWEEN THE AGES 24-31

A person whose disability began between the ages 24 and 31 meets the earnings requirement if Social Security credits have been earned for work in at least one-half of the calendar quarters in the period beginning with the calendar quarter after age 21 and ending with a quarter before age 31 in which the disability exists.

DESCRIPTION OF EARNINGS REQUIREMENT — DISABILITY AT AGE 31 OR LATER — NOT DUE TO STATUTORY BLINDNESS

A person whose disability began at age 31 or later needs to meet two provisions of the earnings requirement: (1) the person needs credit for 20 calendar quarters (5 years) of work during a 40 quarter period (10 years) ending in or after a quarter in which disability exists, and (2) the person needs credit for one calendar quarter of work for each year after 1950 (or after reaching age 21, if that is later) up to the year the disability began. In this second instance, the credits do not have to have been earned during the past 10 years.

DESCRIPTION OF FULLY INSURED TEST — DISABILITY DUE TO STATUTORY BLINDNESS

A person whose disability is due to statutory blindness meets the earnings requirement of the law if one Social Security credit has been earned for each year elapsing after 1950 (or after age 21, if that is later) up to the year the person became blind. A minimum of 6 credits is needed. The credits may have been earned at any time up to the established date of onset.

DWB — EXPLANATION OF THE DISABILITY REQUIREMENT AND THE PRESCRIBED PERIOD

To be considered disabled, a widow, widower, or surviving divorced spouse (age 50 to 60) must have a physical or mental condition that is severe enough to keep a person from working. The condition must have lasted or be expected to last for at least 12 months in a row.

The person's disability must start:

not later than 7 years after the month of death of the wife or husband, or;

for a widow, widower or surviving divorced spouse formerly entitled to mother's or father's benefits not later than 7 years after the month those benefits ended, or;

for a widow/widower or surviving divorced spouse who was previously disabled and who becomes disabled again, not later than 7 years after the period of disability ended.

DESCRIPTION OF EARNINGS REQUIREMENT-SPECIAL INSURED STATUS REQUIREMENTS FOR SUBSEQUENT PERIOD OF DIB

A person who had a period of disability which began before age 31, subsequently recovered, and then became disabled again before or after age 31, can meet the earnings requirement if he/she had one quarter of coverage for every two calendar quarters after age 21 and through the quarter in which the later period of disability began, excluding the prior period of disability.

ALLOWANCE-SUBSEQUENT PERIOD FO DIB, SPECIAL INSURED STATUS-BENEFITS PAYABLE 5/83, FIRST POSSIBLE MONTH OF ENTITLEMENT EARLIER

It is determined your period of disability began 1. Your disability benefits are based on a special provision of the Social Security Act. The first month for which benefits are payable to you under this provision is May 1983.

Fill in:

1. 1. 

   MM/DD/YY (date of onset)

DIB DENIAL — EARNINGS REQUIREMENT NOT MET — NO QC AT ANY TIME

Your Social Security record shows that you do not have credit for any work under Social Security. A disabled person can get disability benefits only if the person worked long enough under Social Security. Since you do not meet the earnings requirement of the law, you cannot get disability benefits.

DIB DENIAL — AOD BEFORE AGE 24 — 6/12 TEST NOT MET IN AOD OR LATER

Your Social Security record shows that you do not meet the earnings requirement of the law. You have earned Social Security credits for only 1 calendar quarters of work in the 12-quarter (3 year) period ending 2. This is the last day of the calendar quarter in which you state you became unable to work because of your condition. Your Social Security record also shows that you do not meet the earnings requirement on any later date. Since you do not meet this requirement, it has not been necessary to decide whether you are disabled within the meaning of the law.

Fill ins:

1. 1. 

   Number of acquired quarters

2. 2. 

   MM/YY

DIB DENIAL — AOD BETWEEN AGES 24-31 EARNINGS REQUIREMENT NOT MET IN AOD OR LATER

Your Social Security record shows that you do not meet the earnings requirement of the law. You have earned Social Security credits for only 1 calendar quarters of work in the period beginning with the first calendar quarter after you reached 21 and ending with 2. This is the last day of the calendar quarter in which you state you became unable to work because of your condition. Your Social Security record also shows that you do not meet the earnings requirement on any later date. Since you do not meet this requirement, it has not been necessary to decide whether you are disabled within the meaning of the law.

Fill ins:

1. 1. 

   Number of quarters

2. 2. 

   MM/YY

DIB DENIAL — AOD AT EARLY AGE — EARNINGS REQUIREMENT NOT MET

Your earnings record shows you do not have enough work credits under Social Security at any time to qualify for disability benefits. Therefore, it has not been necessary to decide whether you are disabled within the meaning of the law.

DIB DENIAL — EARNINGS REQUIREMENT NOT MET IN AOD (AOD 1973 OR LATER) DISABILITY DUE TO STATUTORY BLINDNESS

Your Social Security record shows that you do not meet the earnings requirement of the law. A person whose disability is due to statutory blindness meets the earnings requirement if one Social Security credit has been earned for each calendar year elapsing after 1950 (or after age 21, if that is later) up to the year the disability began. To meet this requirement, you need 1 Social Security credits. You have only 2 credits towards this requirement. Your Social Security record also shows that you do not meet the earnings requirement at any later date. Since you do not meet this requirement, it has not been necessary to decide whether you are disabled within the meaning of the law.

Fill ins:

1. 1. 

   Required quarters

2. 2. 

   Number of credited quarters

DWB DENIAL — DISABLED WHEN ALLEGED OR ONSET ESTABLISHED LATER THAN ALLEGED — PRESCRIBED PERIOD REQUIREMENT NOT MET

To receive disability benefits, your condition must have been disabling within the meaning of the law on or before 1, the date the specified 7-year period ended for you.

After carefully studying the medical evidence in your claim and your statements, it has been determined that your condition first became severe on 2. Since your condition was not disabling within the 7-year period, you are not entitled to disability benefits.

Fill ins:

1. 1. 

   MM/YY

2. 2. 

   MM/DD/YY (date of onset)

DIB DENIAL — DISABLED IN QUARTER ALLEGED OR ONSET ESTABLISHED LATER THAN ALLEGED — DISABLED BEFORE AGE 24 — 6/12 TEST NOT MET

After carefully studying your record and the medical evidence, it has been determined that your condition first prevented you from doing substantial gainful work on 1. However, you do not meet the earnings requirement at that time or at any later time. Your Social Security record shows that you have earned credits for only 2 calendar quarters in the 12-quarter (3-year) period ending 3.

Fill ins:

1. 1. 

   EOD

2. 2. 

   Earned QC's

3. 3. 

   MM/YY

DIB DENIAL — DISABLED IN QUARTER ALLEGED OR ONSET ESTABLISHED LATER THAN ALLEGED — DISABLED BETWEEN THE AGES 24-31 — EARNINGS REQUIREMENT NOT MET

After carefully studying your records and the medical evidence, it has been determined that your condition first prevented you from doing substantial gainful work on 1. However, you do not meet the earnings requirement at that time or any later time. Your Social Security records shows that you have earned credits for only 2 calendar quarters beginning with the first calendar quarter after you reached 21 and ending with the quarter in which you became unable to work because of your condition.

Fill ins:

1. 1. 

   EOD

2. 2. 

   Earned QC's

DIB DENIAL — DISABLED IN QUARTER ALLEGED OR ONSET ESTABLISHED LATER THAN ALLEGED — DISABLED AGE 31 OR LATER — EARNINGS REQUIREMENT NOT MET — DISABILITY NOT DUE TO STATUTORY BLINDNESS

After carefully studying your records and the medical evidence, it has been determined that your condition first prevented you from doing substantial gainful work on 1. But, you do not meet the earnings requirement on that date or on any later date. For a person whose disability began at age 31 or later there are two provisions of the earnings requirement which must be met.

To meet the first provision of the earnings requirement a person needs 20 Social Security credits in the 40-quarter period ending with the quarter in which you became disabled. (a) You have credit for only 2 calendar quarters of work in this period. (b) You have the required quarters.

To meet the second provision of the earnings requirement a person needs one Social Security credit for each year after 1950 (or after reaching age 21, if this is later) up to the year in which you become disabled. You need 3 credits to meet this requirement. (c) You have credit for only 4 quarters of work or (d) You have the required credits.

Fill ins:

1. 1. 

   EOD

2. 2. 

   Earned QC's

3. 3. 

   Required QC's

4. 4. 

   Earned QC's

DIB DENIAL — DISABLED IN QUARTER ALLEGED OR ONSET ESTABLISHED LATER THAN ALLEGED — DISABILITY DUE TO STATUTORY BLINDNESS — EARNINGS REQUIREMENT NOT MET — EOD 1/73 OR LATER

After carefully studying your records and the medical evidence, it has been determined that your condition first prevented you from doing substantial gainful work on 1. But, you do not meet the earnings requirement on that date or on any later date. You need one Social Security credit for each year elapsing after 1950 (or after age 21, if that is later) up to the year you became disabled.

A minimum of 6 credits is needed. The credits may have been earned at any time. In your case, this is a total of 2 credits. Your social security record shows that you have only 3 credits in this period.

Fill ins:

1. 1. 

   EOD

2. 2. 

   Required QC's

3. 3. 

   Earned QC's

CLAIM FILED AFTER DEATH — NOT DISABLED AT ANY TIME EARNINGS REQUIREMENT MET — MEDICAL CONSIDERATION ALONE

1 condition was not disabling on any date through 2, when 3 was last insured for disability benefits. In deciding this, we considered the medical evidence, your statements, and how the condition affected 4 ability to work.

Fill ins:

1. 1. 

   NH's name

2. 2. 

   Date disability I/S last met

3. 3. 

   He/she

4. 4. 

   His/her

DIB — NOT DISABLED BEFORE INSURED STATUS EXPIRED

We have determined that your condition was not disabling on any date through 1, when you were last insured for disability benefits. In deciding this, we studied your records, including the medical evidence and your statements, and considered your age, education, training and work experience in determining how your condition affected your ability to work.

Fill in:

1. 1. 

   Date disability I/S expired

CLAIM FILED AFTER DEATH — NOT DISABLED AT ANY TIME EARNINGS REQUIREMENT MET

1 condition was not disabling on any date through 2, when 3 was last insured for disability benefits. In deciding this, we considered how much 4 condition had affected 4 ability to work. We studied 4 records, including the medical evidence and your statements, and considered 4 age, education, training, and work experience.

Fill ins:

1. 1. 

   NH's name

2. 2. 

   Date disability I/S last met

3. 3. 

   He/she

4. 4. 

   His/her

WIDOW(ER) NOT DISABLED BEFORE PRESCRIBED PERIOD EXPIRED

We have determined that your condition was not disabling on any date before 1, the date your prescribed period ended. In deciding this, we considered the medical evidence and your statements.

Fill in:

1. 1. 

   MM/DD/YY (last day of the P/P)

CLAIM FILED AFTER DEATH — NOT DISABLED — LACK OF SEVERITY — MEDICAL CONSIDERATION ALONE

1 condition was not severe enough to prevent 2 from doing any substantial gainful work, nor was it the cause of death. In deciding this, we considered the medical evidence, your statements, and how the condition affected 3 ability to work.

Fill in:

1. 1. 

   NH's name

2. 2. 

   Him/her

3. 3. 

   His/her

LACK OF SEVERITY (THIS PARAGRAPH IS NOT USED IN CDB DENIALS.)

We have determined that your condition is not severe enough to keep you from working. We considered the medical and other information and work experience in determining how your condition affects your ability to work.

ADVICE REGARDING WORSENING OF CONDITION

If 1 condition gets worse and keeps 2 from working, please contact any Social Security office about filing another application.

Fill ins:

1. 1. 

   Your/claimant's name

2. 2. 

   You/him/her/claimant's name

DWB DENIAL — ADVICE REGARDING WORSENING OF CONDITION

If 1 condition gets worse, please contact any Social Security office about filing another application. The last day of 2 specified 7-year period is 3.

Fill ins:

1. 1. 

   Your/claimant's name

2. 2. 

   Your/his/her/claimant's name

3. 3. 

   MM/DD/YY (last day of the P/P)

ADVICE REGARDING FAILURE TO FOLLOW PRESCRIBED TREATMENT DECISION

If 1 decide to follow prescribed treatment, or if you have more information showing why 2 should not, please contact any Social Security office.

Fill ins:

1. 1. 

   Your/claimant's name

2. 2. 

   Your/claimant's name

ADVICE REGARDING DRUG ADDICTION OR ALCOHOLISM MATERIAL DECISION

If 1 a new or worsening condition other than drug addiction and/or alcoholism, please contact any Social Security office about filing another application.

Fill in:

1. 1. 

   You have/claimant's name has

WIDOW(ER)'S IMPAIRMENT NOT SUFFICIENTLY SEVERE

We have determined that your condition is not severe enough to be considered disabling. In deciding this, we considered the medical evidence and your statements.

CLAIM FILED AFTER DEATH — NOT DISABLED — LACK OF SEVERITY

1 condition was not severe enough to keep 2 from doing any substantial gainful work, nor was it the cause of 3 death. In deciding this, we considered how much 1 condition had affected 3 ability to work. We studied 1 records, including the medical evidence and your statements, and considered 3 age, education, training and work experience.

Fill ins:

1. 1. 

   NH's name

2. 2. 

   Him/her

3. 3. 

   His/her

IMPAIRMENT NOT SEVERE — MEDICAL CONSIDERATION ALONE

We have determined that your condition is not severe enough to be considered disabling. In deciding this, we considered the medical records, your statements, and how your condition affects your ability to work.

DIB — IMPAIRMENT NOT SEVERE — MEDICAL CONSIDERATION ALONE — NOT DISABLED BEFORE INSURED STATUS EXPIRED

We have determined your condition was not disabling on any date through 1, when you were last insured for disability benefits. In deciding this, we considered the medical records, your statements, and how your condition affected you ability to work.

Fill in:

1. 1. 

   Date disability I/S expired

CDB — IMPAIRMENT NOT SEVERE — MEDICAL CONSIDERATION ALONE OR CONDITION DISABLING BUT DID NOT EXIST BEFORE AGE 22 (AGE 22 OR OLDER)

We have determined that your condition was not disabling before age 22. In deciding this, we considered the medical records, your statements and how your condition affected your ability to work.

DIB DENIAL — EXPLANATION OF DISABILITY REQUIREMENT

To be considered disabled, a person must be unable to do any substantial gainful work due to a medical condition which has lasted or is expected to last for at least 12 months in a row. The condition must be severe enough to keep the person from working not only in his or her usual job but in any other substantial gainful work. We look at the person's age, education, training and work experience when we decide whether he or she can work.

CDB — IMPAIRMENT NOT SEVERE — MEDICAL CONSIDERATION ALONE (NOT YET AGE 22)

We have determined that your condition is not disabling. In deciding this, we considered the medical evidence and your statements.

IMPAIRMENT PREVENTS SGA AT TIME OF ADJUDICATION BUT IS NOT EXPECTED TO PREVENT SGA FOR A PERIOD OF 12 MONTHS

We have determined that your condition is not expected to remain severe enough for 12 months in a row to keep you from working. In deciding this, we considered the medical evidence, your statements and how your condition affected your ability to work.

ADVICE REGARDING FAILURE TO IMPROVE — IMPAIRMENT IS SEVERE BUT IS NOT EXPECTED TO LAST 12 MONTHS

If 1 condition does not improve as expected, please contact any Social Security office.

Fill in:

1. 1. 

   Your/claimant's name

APPLICATION FILED AFTER PRIOR DENIAL, CONSIDERATION OF NEW AND FORMER EVIDENCE

In considering your current application of 1, we reviewed not only the new evidence submitted but also all the earlier evidence sent in with your previous application.

Fill in:

1. 1. 

   Date filed

APPLICATION FILED MORE THAN 12 MONTHS AFTER PERIOD OF DISABILITY ENDS

Under the law, a period of disability cannot be established which ends more than 12 months before the month the application is filed.

CLAIM FILED AFTER DEATH — NOT DISABLED — IMPAIRMENT IS SEVERE AT TIME OF DEATH BUT WOULD NOT HAVE BEEN EXPECTED TO LAST 12 MONTHS

1 condition was severe at the time of 2 death; however it was not expected to last for 12 months in a row, nor was it the cause of 2 death. In deciding this, we studied 2 records, including the medical evidence and statements in file, and considered 2 age, education, training and work experience.

Fill ins:

1. 1. 

   NH's name

2. 2. 

   His/her

IMPAIRMENT PREVENTED SGA FOR A PERIOD OF LESS THAN 12 MONTHS

We have determined that your condition was not severe enough for 12 months in a row to keep you from working. In deciding this, we considered the medical evidence, your statements and how your condition affected you ability to work.

CLAIM FILED AFTER DEATH – NOT DISABLED —IMPAIRMENT NO LONGER SEVERE AT TIME OF DEATH AND DID NOT PREVENT SGA FOR A PERIOD OF AT LEAST 12 MONTHS

1 condition was not severe enough for 12 months in a row to keep 2 from working, nor was it the cause of 3 death. In deciding this, we considered how much 1 condition had affected 3 ability to work. We studied 1 records, including the medical evidence and statements in file, and considered 3 age, education, training and work experience.

Fill ins:

1. 1. 

   NH's name

2. 2. 

   Him/her

3. 3. 

   His/her

WIDOW(ER)’S IMPAIRMENT NOT EXPECTED TO PREVENT SGA FOR A PERIOD OF 12 MONTHS

We have determined that your condition is not expected to remain severe enough for 12 months in a row to keep you from working. In deciding this, we considered the medical evidence and your statements.

WIDOW(ER)’S IMPAIRMENT PREVENTED SGA FOR A PERIOD OF LESS THAN 12 MONTHS

We have determined that your condition was not severe enough for 12 months in a row to keep you from working. In deciding this, we considered the medical evidence and your statements.

CDB DENIAL — CLAIMANT ABLE TO ENGAGE IN SGA

We have determined that you are not entitled to childhood disability benefits. After carefully studying your record, it has been determined from the evidence that the work you are doing despite your handicap shows you are able to do some type of substantial gainful work. Therefore, you do not meet the disability requirement of the law.

It is important for you to know that we have not made any determination as to whether or not your medical condition is severe enough to meet the disability requirement. Since you are engaging in substantial gainful work, it has not been necessary to evaluate the severity of your medical condition.

EVIDENCE INSUFFICIENT FOR DISABILITY DECISION — CLAIMANT UNCOOPERATIVE IN SUBMITTING ADDITIONAL EVIDENCE

Under the law, the applicant is responsible for furnishing evidence to support the claim. Although you have been requested to furnish additional evidence, you have not done so. Therefore, a determination has been made based on the evidence in file. This evidence does not show that you are disabled.

CLAIM FILED AFTER DEATH — INSUFFICIENT EVIDENCE

Under the law, the applicant is responsible for furnishing evidence to support his/her disability claim. Although you have been requested to furnish additional evidence, you have not done so. Therefore, a determination has been made based on the evidence in file. This evidence does not show that 1 condition was disabling.

Fill in:

1. 1. 

   NH's name

CDB DENIAL - EVIDENCE INSUFFICIENT FOR DISABILITY DECISION — CLAIMANT COOPERATIVE

In order to be entitled for childhood disability benefits, your impairment must be found to be severe prior to age 22. The evidence in file is not sufficient to fully evaluate your claim and the evidence needed cannot be obtained. Therefore, a determination has been made based on the evidence in file. The evidence does not show that you are disabled on or before your 22nd birthday.

EVIDENCE INSUFFICIENT FOR DISABILITY DECISION — CLAIMANT REFUSES OR DOES NOT REPORT FOR CONSULTATIVE EXAMINATION

The evidence we now have does not show that your condition is disabling. We based our determination on this evidence because you did not take the medical examination we asked you to have at our expense. The examination was needed to fully evaluate your condition.

CLAIMANT DOES NOT WISH TO PURSUE — WANTS DECISION ON EVIDENCE IN FILE

Since you did not wish to continue the processing of your claim, we determined, based on the evidence in your file, that your condition is not disabling.

DIB, CDB, DWB — CLAIMANT DOES NOT PURSUE AND DOES NOT INDICATE DECISION TO BE MADE ON EVIDENCE IN FILE

Since you did not wish to continue the processing of your claim, we determined, based on the evidence in your file, that your condition is not disabling. You may withdraw your claim and this determination will no longer be in effect. Your Social Security office will assist you if you wish to withdraw.

CLAIM FILED AFTER DEATH — DENIAL — APPLICANT DOES NOT WANT TO CONTINUE DEVELOPMENT OF CLAIM

Since you did not wish to continue the processing of 1 claim, we determined, based on the evidence in file, that 2 was not disabled.

Fill ins:

1. 1. 

   NH's name

2. 2. 

   He/she

FREEZE DOES NOT INCREASE RIB CURRENTLY PAYABLE

R

Since the amount of your benefit would not be increased by refiguring it under the disability provision, we are denying your application for a disability determination. Your benefit amount will continue unchanged.

APPLICANT MENTIONS ANOTHER DISABILITY PROGRAM

Definitions of disability are not the same in all government and private disability programs. Government agencies must follow the particular laws which apply to their disability programs. Therefore, a finding by a private organization or another government agency that a person is disabled would not necessarily mean that the person is disabled as defined in the Social Security Act.

REEXAMINATION SCHEDULED — BENEFICIARY HOSPITALIZED

The evidence in your claim shows that your condition may soon improve. Therefore, we plan to get in touch with you about 1 to see if your are still eligible to receive disability benefits. To help us determine this, we may ask you to submit additional medical evidence or go for a medical examination. If we find you are still disabled, your benefits will continue. But, if our review shows you are no longer disabled, your benefits will be stopped.

RESPONSIBILITIES OF PEOPLE RECEIVING DISABILITY BENEFITS

Please notify us promptly if you should leave the hospital. You should also report, without delay, any of the other events listed in the enclosed booklet.

If you have questions about your claim, the people in any Social Security office will be glad to help you. You can find the telephone number and address in the telephone book under “Social Security Administration,” or ask for this information at your local post office.

Enclosure: SSA-10153

Fill in:

1. 1. 

   MM/YY (re-exam date)

STATUTORY BLINDNESS — DIB ALLOWANCE UNDER 1972 AMENDMENTS — FIRST MONTH OF ENTITLEMENT RESTRICTED TO 1/73

Under the law, in effect before 1972, disability benefits were payable only if a disabled individual was fully insured and had 20 Social Security credits in the 40-quarter (10-year) period ending in or after a quarter in which he was disabled. Although you meet the disability requirement and are fully insured, your Social Security record shows that you have only 1 credits in the 40-quarter period ending 2, the last day of the calendar quarter in which you became disabled. Thus, you do not meet the earnings requirement in effect before the 1972 amendments.

The 1972 amendments changed the earnings requirement a statutorily blind person must meet to be entitled to disability benefits. It has been determined that you meet the new requirement. You are entitled to disability insurance benefits beginning with the month shown above. This is the earliest date benefits can be paid under the 1972 amendments to the Social Security Act.

Fill ins:

1. 1. 

   Earned QC's

2. 2. 

   MM/YY

NOTICE TO NH WHEN DISABILITY DENIED IN DIB/RIB CLAIM

To be considered disabled for Social Security purposes, you must be unable to perform any substantial gainful work because of a physical or mental impairment which has lasted or is expected to last at least 12 continuous months or is expected to result in death.

INITIAL NOTICE — REFERENCE TO FOLLOW-UP NOTICE IF TITLE II UNDERPAYMENT OR OVERPAYMENT INVOLVED

You will be notified at a later date if an underpayment or overpayment of benefits exists on your claim.

LEAD-IN PARAGRAPH — UNDERPAYMENT OF TITLE II BENEFITS INVOLVED

You were previously notified in our notice dated 1 that the last payment to which you are entitled is for the month of 2. This follow-up notice is to inform you about the underpayment on your claim.

Fill ins:

1. 1. 

   Date initial cessation notice

2. 2. 

   Input DOST minus 1 month

LEAD-IN PARAGRAPH — OVERPAYMENT OF TITLE II BENEFITS INVOLVED

You were previously notified in our notice dated 1 that the last payment to which you are entitled is for the month of 2. This follow-up notice is to inform you about the overpayment on your claim.

Fill ins:

1. 1. 

   Date initial cessation notice

2. 2. 

   Input DOST minus 1 month

LEAD-IN PARAGRAPH — MEDICAL PREMIUMS DUE

You were previously notified in our notice dated 1 that the last payment to which you are entitled is for the month of 2. This follow-up notice is to inform you about the medical premiums due on your claim.

Fill ins:

1. 1. 

   Date initial cessation notice

2. 2. 

   Input DOST minus 1 month

DIB-RATE INCREASE — TWO RATES PAYABLE

As a result of a change in the law, you are entitled to disability benefits in two different amounts beginning at two different times. Under the previous law, you were entitled to the smaller amount. Under the current law, your benefits have been refigured and you are entitled to a larger amount.

DIB — RATE INCREASE — CHANGE IN DISABILITY PERIOD

Your monthly disability insurance benefit has been increased to the amount shown above. The first payment will include the difference due for back benefits from the date of entitlement shown above. This increase is paid because of a recent change in the disability provisions of the Social Security Act permitting the use of a longer period of disability for you than was possible when you filed your application.

CLAIMANT INSURED FOR RIB — NO RIB CLAIM FILED

Your present earnings record and the date of birth you gave us show that you have enough credit for work under Social Security to qualify for retirement insurance benefits at age 62.

INFORMATION CONCERNING HOSPITAL AND MEDICAL INSURANCE — CLAIMANT AGE 63-64 3/4

You may be eligible for hospital and medical insurance benefits when you reach 65. If you wish to enroll for this health insurance, please get in touch with any Social Security office about 3 months before you become 65.

DIB AND DWB APPLICATIONS FILED

R

If you have not already been informed about the determination on your other disability application, you can expect to be notified shortly.

FAILS TO FOLLOW PRESCRIBED TREATMENT

We have determined that you are not entitled to 1 because you are not following the treatment prescribed for you. A person who is unable to do substantial gainful work may qualify for 2, but not if he/she refuses to follow prescribed treatment that could restore his/her ability to work.

Fill ins:

1. 1. 

   Disability benefits/supplemental security income payments

2. 2. 

   Benefits/payments

CLAIM FILED AFTER DEATH — DENIAL — IMPAIRMENT WAS SEVERE BUT NUMBER HOLDER FAILED TO FOLLOW PRESCRIBED TREATMENT

1 was not entitled to disability benefit because 2 was not following the treatment prescribed for 3 at the time of 4 death. A person who is unable to do substantial gainful work may qualify for disability benefits, but not if he/she refuses to follow prescribed treatment that could restore his/her ability to work.

Fill ins:

1. 1. 

   NH's name

2. 2. 

   He/she

3. 3. 

   Him/her

4. 4. 

   His/her

CHILDHOOD DISABILITY CLAIM — DENIAL — IMPAIRMENT IS SEVERE BUT CLAIMANT FAILS TO FOLLOW PRESCRIBED TREATMENT

We have determined that you are not entitled to childhood disability benefits. The evidence shows that you are unable to perform substantial gainful work due to your condition, but that you are not following the treatment which has been prescribed for you. Therefore, childhood disability benefits may not be paid to you.

Childhood disability insurance benefits may be paid to a person age 18 or older if the person is unable to perform any substantial gainful work due to a medically determinable impairment which began before age 22.

Despite prescribed treatment, the condition must have lasted or be expected to last, for a continuous period of at least 12 months. However, if a person refuses to follow prescribed treatment that could restore the individual's ability to work, the person may not become entitled to childhood disability benefits.

If you should decide to follow the prescribed treatment, or if you have more information showing why you should not, please get in touch with any Social Security office.

FREEZE CESSATION — MEDICAL IMPROVEMENT (W/E RECEIVING REDUCED RIB)

The law provides that an individual's disability freeze shall end if his condition improves so that the person becomes able to do substantial gainful work. The law also provides that an individual's freeze period will continue for the month the disability ends and the following two months. The medical evidence in your case shows that your condition has improved to the extent that you became able to do substantial gainful work in 1. Accordingly, the last month of your disability freeze is 2. This decision is based on all the evidence in your file, including any additional evidence you may have submitted.

Fill ins:

1. 1. 

   MM/YY

2. 2. 

   MM/YY

FREEZE CESSATION — WORK ACTIVITY (W/E RECEIVING REDUCED RIB)

The law provides that an individual's disability freeze shall end if the person becomes able to do substantial gainful work. The law also provides that an individual's freeze period will continue for the month the disability ends and the following 2 months. The evidence in your case shows that you became able to do substantial gainful work in 1. Accordingly, the last month of your disability freeze is 2. This decision is based on all the evidence in your file, including any additional evidence you may have submitted.

Fill ins:

1. 1. 

   MM/YY

2. 2. 

   MM/YY

FREEZE OR DIB CONTINUANCE (AFTER FULL RETIREMENT AGE)

The law provides that a disability period shall end when an individual reaches full retirement age or again becomes able to do substantial gainful work, whichever occurs first. On the basis of the evidence in your case, we find that your disability continued until you reached full retirement age.

DWB CESSATION — MEDICAL IMPROVEMENT

You have been receiving benefits under a special provision of the Social Security Act which provides for the payment of benefits to disabled widows and widowers under age 60. To qualify for such benefits an individual must have a condition so severe as to ordinarily prevent her/him from working. Medical conditions which meet this requirement are described in the Social Security Regulations; disability benefits end when this requirement is not met. The law continues benefits, however, for 2 months after the month in which the person's condition does not meet the disability requirement of the law. The medical evidence in your case shows that your condition does not meet the disability requirement of the law in 1. Accordingly, the last disabled 2 benefit check to which you are entitled is for the month of

3.

If your condition worsens you should contact your Social Security office about filing a new application.

Fill ins:

1. 1. 

   MM/YY

2. 2. 

   Widow's/widower's

3. 3. 

   MM/YY

DIB CESSATION — OVERPAYMENT INVOLVED

Our records show you received $1 more in Social Security benefits than you should have. This is because you were paid benefits for 2 months after 3.

Fill ins:

1. 1. 

   Amount of overpayment

2. 2. 

   Number of months overpaid

3. 3. 

   Last MM/YY benefits are due

(2)

DIB CESSATION — OVERPAYMENT INVOLVED — SMI PREMIUMS INCLUDED IN OVERPAYMENT

Our records show you received $1 more in Social Security benefits than you should have. This happened because you were paid benefits for 2 months after 3. The above amount includes medical insurance premiums of $4 which were withheld from your benefit check(s) for the same period.

Fill ins:

1. 1. 

   Amount of overpayment

2. 2. 

   Number of months overpaid

3. 3. 

   Last MM/YY benefits are due

4. 4. 

   Amount of medical insurance premiums included in the overpayment

DIB CESSATION — UNDERPAYMENT INVOLVED FOR ONE MONTH

Since you were last paid for the month of 1, you are due benefits for 2. You may expect to receive a check in the amount of $3 from the Treasury Department within a few days. This check will represent all payment due you.

Fill ins:

1. 1. 

   MM/YY (last month benefit paid)

2. 2. 

   MM/YY (month payment is due)

3. 3. 

   Amount of check

DIB CESSATION — UNDERPAYMENT INVOLVED FOR MULTIPLE MONTHS

Since you were last paid for the month of 1, you are due benefits for 2 through 3. You may expect to receive a check in the amount of $ 4 from the Treasury Department within a few days. This check will represent all payments due you.

Fill ins:

1. 1. 

   Month/year (last month benefit paid)

2. 2. 

   Month/year (first month benefit payment is due)

3. 3. 

   Month/year (last month benefit payment is due)

4. 4. 

   Amount of check

TITLE II “LEAD-IN” PARAGRAPH

This notice concerns your continuing entitlement to benefits under the Social Security Disability program.

REQUEST FOR REFUND

You should refund the amount shown above within 30 days from the receipt of this letter. Please make your check or money order payable to “Social Security Administration, Claim No. 1,” and send it to us in the enclosed envelope.

Enclosure: Envelope

Fill in:

1. 1. 

   Claim number (include BIC)

DWB CESSATION (NO TRIAL WORK PERIOD)

A widow, widower or surviving divorced spouse may be considered disabled for Social Security purposes only if she or he has a medical condition that is so severe as to ordinarily prevent an individual from working. Widow's or widower's benefits based on disability end if she or he engages in substantial gainful activity since she or he is no longer considered to be disabled within the meaning of the law. The law continues her or his benefits, however, for the month in which disability ends and the following two months. The evidence in your case shows that you became able to do substantial gainful activity in 1. Accordingly, the last widow's or widower's benefit to which you are entitled is for the month of 2 . If your condition again prevents you from working, you should contact your Social Security office about filing a new application.

Fill ins:

1. 1. 

   MM/YY

2. 2. 

   MM/YY

DWB CESSATION (TRIAL WORK PERIOD)

A widow, widower or surviving divorced spouse may be considered disabled for Social Security purposes only if she or he has a medical condition that is so severe as to ordinarily prevent an individual from working. Widow's or widower's benefits based on disability end if she or he engages in substantial gainful activity since she or he is no longer considered to be disabled within the meaning of the law. The law continues her or his benefits, however, for the month in which disability ends and the following two months. Not until a person has performed services in at least 9 months is a decision made as to whether the person has become able to do substantial gainful work. The evidence in your case shows that you have performed services in at least 9 months and that you became able to do substantial gainful work in 1. Accordingly, that last widow's or widower's benefit to which you are entitled is for the month of 2. If your condition again prevents you from working, you should contact your Social Security office about filing a new application.

Fill ins:

1. 1. 

   MM/YY

2. 2. 

   MM/YY

AOD BEFORE AGE 62 YEARS 7 MONTHS BUT ONSET CANNOT BE ESTABLISHED BEFORE AGE 62 YEARS 7 MONTHS OR LATER — LESS THAN 29 MONTHS OF PAST AND/OR FUTURE DISABILITY ENTITLEMENT PRIOR TO AGE 65

We have determined that you are not entitled to Medicare coverage for the disabled. However, you may be entitled to Medicare coverage at age 65, whether or not you are disabled. A person must be disabled for 1 months before his/her Medicare coverage begins. Because your condition was not disabling on any date through 2, your Medicare coverage could not begin until you reach age 65.

Fill ins:

1. 1. 

   29 (for NH and disabled widow(er) claims/24 (for disabled child claims)

2. 2. 

   Date claimant is age 62 and 7 months (for NH or disabled widow(er) claims/date claimant is age 63 (for CDB claims).

UNDERPAYMENT AWARD IN ADDITION TO OTHER AWARD (BENEFIT OF WIFE INCLUDED WITH PAYMENT)

This payment includes unpaid benefits which were due your husband. It also includes wife's benefits due you.

DISABILITY CEASES — PAYMENTS CONTINUE

Medical evidence shows that you became able to do substantial gainful work in 1. Even though you are able to work, you will get disability benefits. Your benefits will continue because you are in an approved vocational rehabilitation program that you started when your condition was not expected to improve.

We will contact you in 2 to see if you are still in the program. If your program stops or changes before that date, let us know.

Fill ins:

1. 1. 

   MM/YY disability ceased

2. 2. 

   MM/YY of VR follow up

PERSONALIZED NOTICE LEAD-IN

Attached is an explanation of how we decided your claim.

TITLE II — VR CESSATION — AUXILIARIES IN SEPARATE HOUSEHOLDS — PAYMENTS CONTINUE

We have determined that 1 is no longer disabled under the Social Security law. However, benefits will be continued because of the wage earner's participation in a State vocational rehabilitation program.

If you are not satisfied with our finding that the worker's period of disability ended, you may request that your case be reexamined not later than 60 days from the date you receive this notice even though your payments are being continued based on vocational rehabilitation involvement.

Fill-in:

1. 1. 

   Name of primary beneficiary

TITLE II — VR CESSATION — AUXILIARIES IN SAME HOUSEHOLD — PAYMENTS CONTINUE

Due to your participation in a State vocational rehabilitation plan, benefits to 1 will continue.

Fill in:

1. 1. 

   Your family/your wife/your children/your child

DISABILITY CEASES — PAYMENTS TERMINATE

Your benefits will stop because evidence shows that you recovered enough to do substantial gainful work in 1.

Fill in:

1. 1. 

   MM/YY disability ceased

If you were in an approved State vocational rehabilitation program you might be able to keep getting benefits.

Appropriate paragraph from the following:

1) However, rehabilitation records show that your program ended in 1.

Fill in:

1. 1. 

   MM/YY VR program ended

2) However, the rehabilitation agency records show that you stopped taking part in an approved program in 1.

Fill in:

1. 1. 

   MM/YY active participation in VR program ended

3) We have determined that you are not eligible for continued payments because your vocational rehabilitation program will not give you new special skills or a job at the end of the program.

4) We have determined that you are not entitled to continued payments because your disability claim was set for review in 1. This means you were expected to recover before your rehabilitation program ends in 2.

Fill ins:

1. 1. 

   MM/YY of review

2. 2. 

   MM/YY rehabilitation program will end

5) Your disability ended 1 and your vocational rehabilitation program ended 2. Continued payment is not possible because your vocational program ended before your last month of entitlement of disability benefits.

Fill ins:

1. 1. 

   MM/YY disability ceased

2. 2. 

   MM/YY VR program ended

6) Although you are in a vocational rehabilitation program, your program was approved after your disability ended.

1 is the last month you are entitled to 2. 3 payments are paid for the month disability ends and for the 2 following months.

Fill ins:

1. 1. 

   MM/YY disability terminated

2. 2. 

   A disability benefit/a supplemental security income payment

3. 3. 

   Disability/Supplemental Security income

TITLE II — VR CONTINUED PAYMENTS — TERMINATION PARAGRAPH

Our 1 notice to you explained that you would get disability benefits as long as you were in an approved vocational rehabilitation program. Because your program ended 2, your disability benefits must also end then.

If you do not agree with this decision, you can ask to have your claim reviewed.

Fill ins:

1. 1. 

   MM/YY or earlier

2. 2. 

   MM/YY VR program termination

TITLE XVI — VR CONTINUED PAYMENTS — TERMINATION PARAGRAPH

Our 1 notice to you explained that you would get disability benefits as long as you were in an approved vocational rehabilitation program. Because your program ended 2 your disability benefits must also end then.

If you do not agree with this decision, you can ask for a hearing by the Office of Hearings and Appeals.

Fill ins:

1. 1. 

   MM/YY or earlier

2. 2. 

   MM/YY VR program termination

TITLE II — VR CESSATION — AUXILIARIES IN SEPARATE HOUSEHOLDS — VR PAYMENTS TERMINATE

This notice concerns your continuing eligibility to benefits.

We cannot continue to pay you benefits. The person on whose Social Security record you filed a claim is no longer entitled to continued payments because he or she is no longer participating in a State vocational rehabilitation program.

Therefore, 1 is the last month you will receive benefits.

Fill in:

1. 1. 

   MM/YY disability terminated

TITLE XVI CLAIM ESCALATED TO RECONSIDERATION LEVEL

Because you had already requested reconsideration on your Social Security disability claim when you filed your Supplemental Security Income claim, we processed your Supplemental Security Income claim as though you had requested reconsideration on it as well. Thus, this determination is both an initial and reconsideration determination.

TITLE II — VR CESSATION — AUXILIARIES IN THE SAME HOUSEHOLD — VR PAYMENTS TERMINATE

This notice concerns 1 continuing eligibility to benefits. We cannot continue to pay 2 benefits because you are no longer participating in a State vocational rehabilitation program, and therefore are no longer entitled to continued payments. Therefore, 3 is the last month benefits are payable.

Fill ins:

1. 1. 

   Your family's/your wife's/your children's/your child's

2. 2. 

   Him/her/them

3. 3. 

   MM/YY disability terminated

INCREASE IN RATE — BENEFITS PAYABLE AT BOTH RATES

The increase in the rate of benefits beginning 1 is possible due to the termination of benefits to 2 effective that month.

Fill ins:

1. 1. 

   MM/YY

2. 2. 

   Name of terminated beneficiary

DECREASE IN RATE — BENEFITS PAYABLE AT BOTH RATES

The higher rate of benefit allowed before 1 is possible because 2 did not become entitled to benefits until that month. Thereafter, it was necessary under the provisions of the Social Security Act, that the rate be reduced as shown above.

Fill ins:

1. 1. 

   MM/YY

2. 2. 

   Name of beneficiary

CHANGE IN BENEFIT RATE

The benefits payable on this claim have been refigured. The new monthly rate and its effective date are shown above.

CHANGE IN BENEFIT RATE — INCREASE OR DECREASE IN BENEFITS FOR RETROACTIVE PERIOD

The benefits payable on this claim have been refigured. The new monthly rate and its effective date are shown above. Your first payment will have been adjusted for the difference between benefits already paid and those now payable.

BENEFICIARY'S BENEFIT RATE ADJUSTED DUE TO TERMINATION OF BENEFITS TO ANOTHER BENEFICIARY

The benefit rate has been increased due to 1 of 2 on 3.

Fill ins:

1. 1. 

   Reason (item 11 of the SSA-101)

2. 2. 

   Name

3. 3. 

   Date (item 11 of the SSA-101)

CHANGE IN ONE BENEFICIARY'S RATE — WAGE EARNER'S AND SPOUSE'S BENEFITS COMBINED

R

The benefit payable to you has been combined with the benefit payable to your spouse.

FORM SSA-L562-U3 CHANGE IN RATE REASONS

Indicate only one reason for the fill-in space on the form:

1. A. 

   To correct the previous calculation

2. B. 

   To give credit for additional earnings

3. C. 

   To increase the rate because the benefits of another person have been terminated

4. D. 

   To decrease the rate because another person is now entitled to benefits

5. E. 

   To increase the rate because a period of disability has been established

6. F. 

   To give credit for months of entitlement before full retirement age (62) for which less than the full benefit was paid

7. G. 

   To give credit for months of entitlement before full retirement age for which benefits were paid based on caring for a child who was entitled to benefits

8. H. 

   To give credit for months your deceased spouse was entitled to, but not paid, full benefits between age 62 and 65

9. I. 

   To give credit for months when you were at least full retirement age and did not receive a retirement benefit because you were working

10. J. 

    Because of a special provision of the law. This special provision increases benefits for people who have worked under Social Security for many years at relatively low earnings

11. K. 

    To give credit for additional earnings and also to give credit for months after 1970 when you were at least full retirement age and did not receive a retirement benefit because you were working

12. L. 

    To increase the benefits based on your amended annual report of earnings which shows you worked in fewer months after full retirement age than you had originally reported

13. M. 

    To give credit for months your deceased spouse was at least 65 and did not receive a retirement benefit because of work

DWB AND DIB AFFIRMATION OF DENIAL, CESSATION OR ONSET DATE — NON STATE — NO PHYSICIAN PARTICIPATION

Upon receipt of your request for reconsideration, we had your claims for disabled 1 benefits and disability insurance benefits independently reviewed by a special group. All the evidence in your case has been carefully evaluated; this includes the medical evidence and the additional information received since the original decision. On the basis of the evidence and your statements, we find that the previous determinations were proper under the law.

Fill in:

1. 1. 

   Widow/widower/surviving divorced wife's/surviving divorced husband's

DWB AND DIB — AFFIRMATION OF DENIAL, CESSATION OR ONSET DATE NON STATE — PHYSICIAN PARTICIPATION

Upon receipt of your request for reconsideration, we had your claim for disabled 1 benefits and disability insurance benefits independently reviewed by a specially designated group composed of disability examiners and a physician. All the evidence in your case has been carefully evaluated; this includes the medical evidence and the additional information received since the original decision. On the basis of the evidence and your statements, we find that the previous determinations were proper under the law.

Fill in:

1. 1. 

   Widow's/widower's/surviving divorced wife's/surviving divorced husband's

DWB AND DIB — AFFIRMATION OF DENIAL, CESSATION OR ONSET DATE — STATE — PHYSICIAN PARTICIPATION

Upon receipt of your request for reconsideration, we had your claims for disabled 1 benefits and disability insurance benefits re-evaluated by a physician and a disability examiner in the State agency which works with us in making disability determinations. All the evidence in your case has been carefully evaluated; this includes the medical evidence and the additional information received since the original decision. This new evaluation was then independently reviewed in the Social Security Administration. On the basis of the evidence and your statements, we have determined that the previous determinations were proper under the law.

Fill in:

1. 1. 

   Widow's/widower's/surviving divorced wife's/surviving divorced husband's

DIB OR FREEZE AFFIRMATION OF DENIAL, CESSATION OR ONSET DATE — NON-STATE NO PHYSICIAN PARTICIPATION

Upon receipt of your request for reconsideration, we had your claim independently reviewed by a special group. All the evidence in your case has been carefully evaluated; this includes the medical evidence and the additional information received since the original decision. On the basis of the evidence, and considering your age, education, training, and work experience, we find that the previous determination was proper under the law.

DIB OR FREEZE — AFFIRMATION OF DENIAL, CESSATION OR ONSET DATE — NON-STATE — PHYSICIAN PARTICIPATION

Upon receipt of your request for reconsideration, we had your claim independently reviewed by a specially designated group composed of disability examiners and a physician. All the evidence in your case has been carefully evaluated; this includes the medical evidence and the additional information received since the original decision. On the basis of the evidence, and considering your age, education, training and work experience, we find that the previous determination was proper under the law.

DIB OR FREEZE — AFFIRMATION OF DENIAL, CESSATION OR ONSET DATE — STATE — PHYSICIAN PARTICIPATION

Upon receipt of your request for reconsideration, we had your claim re-evaluated by a physician and a disability examiner in the State agency which works with us in making disability determinations. All the evidence in your case has been carefully evaluated; this includes the medical evidence and the additional information received since the original decision. This new evaluation was then independently reviewed in the Social Security Administration. On the basis of the evidence, and considering your age, education, training and work experience, we have determined that the previous determination was proper under the law.

CDB — AFFIRMATION OF DENIAL OR CESSATION — NON-STATE — NO PHYSICIAN PARTICIPATION

Upon receipt of the request for reconsideration we had the claim for childhood disability benefits independently reviewed by a special group. All the evidence in the case has been carefully evaluated; this includes the medical evidence and the additional information received since the original decision. On the basis of the evidence, and considering the claimant's education and training, we find that the previous determination was proper under the law.

CDB — AFFIRMATION OF DENIAL OR CESSATION — NON STATE — PHYSICIAN PARTICIPATION

Upon receipt of the request for reconsideration, we had the claim for childhood disability benefits independently reviewed by a specially designated group composed of disability examiners and a physician. All the evidence in the case has been carefully evaluated; this includes the medical evidence and the additional information received since the original decision. On the basis of the evidence, and considering the claimant's education and training, we find that the previous determination was proper under the law.

CDB — AFFIRMATION OF DENIAL OR CESSATION — STATE — PHYSICIAN PARTICIPATION

Upon receipt of the request for reconsideration, we had the claim for childhood disability benefits reevaluated by a physician and disability examiner in the State agency which works with us in making disability determinations. All the evidence in the case has been carefully evaluated; this includes the medical evidence and the additional information received since the original decision. This new evaluation was then independently reviewed in the Social Security Administration. On the basis of the evidence and considering the claimant's education and training, we have determined that the previous determination was proper under the law.

DIB, DWB AND CDB - PARTIALLY FAVORABLE INITIAL ALLOWANCE TO A RECONSIDERATION DENIAL

Upon receipt of your request for reconsideration, we had your claim independently reviewed by a special team composed of a disability examiner and a medical consultant(s). The team carefully evaluated all of the evidence in your case, including the medical evidence from our original decision and any new information we received after that decision. Based on this evidence, we find that the previous determination was improper under the law. We have changed our original decision and determined that you have not been “disabled” within the meaning of the law at any time relevant to your application.

DIB — NOT DISABLED — GENERAL

To be considered disabled for Social Security purposes you must have a medical condition which prevents you from doing not only your usual work but also any other type of substantial gainful activity.

DIB — NOT DISABLED — EARNINGS TEST HAS EXPIRED OR WILL EXPIRE IN OR BEFORE THE QUARTER FOLLOWING THE DATE THE LETTER IS PREPARED.

To be considered disabled for Social Security purposes you must have a medical condition which prevents you from doing not only your usual work but also any other type of substantial gainful activity. In addition, the disability must exist at a time when another requirement called the earnings requirement is met. Your Social Security record at the time of your application showed that you 1 this requirement on 2.

Fill ins:

1. 1. 

   Will last meet/last met

2. 2. 

   MM/DD/YY (date last insured)

DIB — NOT DISABLED WHEN EARNINGS TEST LAST MET — AOD BEFORE AGE 24

To be considered disabled for Social Security purposes you must have a medical condition which prevents you from doing not only your usual work but also any other type of substantial gainful activity. This inability to work must exist at a time when another requirement called the earnings requirement is met.

A person whose disability began before age 24 must have Social Security credits for 6 calendar quarters (1 1/2 years) of work during a 12-quarter (3 year) period ending with a quarter before age 24 in which he/she is disabled. Your Social Security record shows that you last met this earnings requirement on 1. For you to qualify for benefits, your disability must have begun on or before that date.

Fill in:

1. 1. 

   MM/DD/YY (date last insured)

DIB — NOT DISABLED WHEN EARNINGS TEST LAST MET — AOD BETWEEN AGES 24-31

To be considered disabled for Social Security purposes you must have a medical condition which prevents you from doing not only your usual work but also any other type of substantial gainful activity. This inability to work must exist at a time when another requirement called the earnings requirement is met.

A person whose disability began between the ages 24 and 31 must have Social Security credits for work in at least one-half the calendar quarters in the period beginning with the calendar quarter after age 21 and ending with a quarter before age 31 in which he/she is disabled. Your Social Security record shows that you last met this earnings requirement on 1. For you to qualify for benefits your disability must have begun on or before that date.

Fill in:

1. 1. 

   MM/DD/YY

DIB NOT DISABLED WHEN EARNINGS TEST LAST MET — AOD AT OR AFTER AGE 31 — (Disability Not Due to Statutory Blindness)

To be considered disabled for Social Security purposes, a person must have a medical condition which prevents him/her from doing not only his/her usual work but also any other type of substantial gainful activity. This inability to work must exist at a time when another requirement called the earnings requirement is met.

A person whose disability began at age 31 or later needs to meet two provisions of the earnings requirement. First, he/she needs credit for 20 calendar quarters (5 years) of work during a 40-quarter period (10 years) ending in or after a quarter in which he/she is disabled. And second, he/ she needs credit for one calendar quarter of work for each year after 1950 (or after reaching age 21, if this is later) up to the year the disability began. In the second instance, the credits may have been earned at any time.

DIB — EXPLANATION OF DISABILITY REQUIREMENT

To be considered disabled for Social Security purposes a person must be unable to engage in any substantial gainful activity due to a medical condition which has lasted or can be expected to last for a continuous period of at least 12 months. His/Her impairment must be so severe as to prevent him /her from engaging not only in his/her usual occupation but also in any other kind of substantial gainful work, considering his/her age, education, and work experience. This inability to work must exist at a time when another requirement called the earnings requirement is met.

DIB — EXPLANATION OF DISABILITY REQUIREMENT — EARNINGS TEST NOT EXPIRED

To be considered disabled for Social Security purposes a person must be unable to engage in any substantial gainful activity due to a medical condition which has lasted or can be expected to last for a continuous period of at least 12 months. His/Her impairment must be so severe as to prevent him /her from engaging not only in his/her usual occupation but also in any other kind of substantial gainful work considering his/her age, education, and work experience. This inability to work must exist at a time when another requirement called the earnings requirement is met. Your Social Security record shows that you meet this earnings requirement until 1.

Fill in:

1. 1. 

   MM/DD/YY (date last insured)

DIB — EXPLANATION OF DISABILITY REQUIREMENT — EARNINGS TEST EXPIRED — ADD BEFORE AGE 24

To be considered disabled for Social Security purposes a person must be unable to engage in any substantial gainful activity due to a medical condition which has lasted or can be expected to last for a continuous period of at least 12 months. His/Her impairment must be so severe as to prevent him /her from engaging not only in his/her usual occupation but also in any other kind of substantial gainful work, considering his/her age, education and work experience. This inability to work must exist at a time when the earnings requirement is met.

A person whose disability began before age 24 must have Social Security credits for 6 calendar quarters (1 1/2 years) of work during a 12-quarter (3 year) period ending with a quarter before age 24 in which he/she is disabled. Your Social Security record shows you last met the earnings requirement on 1.

Fill in:

1. 1. 

   MM/DD/YY (date last insured)

DIB-EXPLANATION OF DISABILITY REQUIREMENT-EARNINGS TEST EXPIRED-AOD BETWEEN AGES 24-31

To be considered disabled for Social Security purposes a person must be unable to engage in any substantial gainful activity due to a medical condition which has lasted or can be expected to last for a continuous period of at least 12 months. His/Her impairment must be so severe as to prevent him /her from engaging not only in his/her usual occupation but also in any other kind of substantial gainful work, considering his/her age, education and work experience. This inability to work must exist at a time when the earnings requirement is met.

A person whose disability began between the ages 24 and 31 must have Social Security credits for work in at least one-half the calendar quarters in the period beginning with the calendar quarter after age 21 and ending with a quarter before age 31 in which he/she is disabled. Your Social Security record shows you last met the earnings requirement on 1.

Fill in:

1. 1. 

   MM/DD/YY (date last insured)

DIB - EXPLANATION OF DISABILITY REQUIREMENT - EARNINGS TEST EXPIRED - AOD AT OR AFTER AGE 31

(Disability Not Due to Statutory Blindness)

To be considered disabled for Social Security purposes a person must be unable to engage in any substantial gainful activity due to a medical condition which has lasted or can be expected to last for a continuous period of at least 12 months. His/Her impairment must be so severe as to prevent him /her from engaging not only in his/her usual occupation but also in any other kind of substantial gainful work, considering his/her age, education and work experience. This inability to work must exist at a time when the earnings requirement is met.

A person whose disability began at age 31 or later needs to meet two provisions of the earnings requirement. First, he/she needs credit for 20 calendar quarters (5 years) of work during a 40-quarter period (10 years) ending in or after a quarter in which he/she is disabled. And second, he/she needs credit for one calendar quarter to work for each year after 1950 (or after reaching age 21, if that is later) up to the year his/her disability began. In the second instance, the credits may have been earned at any time.

Your Social Security record shows you last met the earnings requirement on 1.

Fill in:

1. 1. 

   MM/DD/YY (date last insured)

DIB - DISABLED IN QUARTER ALLEGED OR ONSET ESTABLISHED LATER THAN ALLEGED - EARNINGS REQUIREMENT NOT MET - EOD BEFORE AGE 24

To meet the earnings requirement a person whose disability began before age 24 must have Social Security credits for 6 calendar quarters (1 1/2 years) of work during a 12-quarter (3-year) period ending with a quarter before age 24 in which he/she is disabled.

After careful review it has been determined that your condition first prevented you from doing substantial gainful work on 1. However, your Social Security record shows that you do not meet the earnings requirement at that time or at any later date. You have earned credits for only 2 calendar quarters in the period ending 3.

Fill ins:

1. 1. 

   EOD

2. 2. 

   Earned QC's

3. 3. 

   MM/YY

DIB - DISABLED IN QUARTER ALLEGED OR ONSET ESTABLISHED LATER THAN ALLEGED - EARNINGS REQUIREMENT NOT MET - EOD BETWEEN THE AGES 24-31

To meet the earnings requirement, a person whose disability began between the ages 24 and 31 must have Social Security credits for work in at least one-half the calendar quarters in the period beginning with the calendar quarter after age 21 and ending with a quarter before age 31 in which he/she is disabled.

After careful review we have determined that your condition first prevented you from doing substantial gainful work on 1. However, your Social Security record shows that you do not meet the earnings requirement at that time or at any later date. You have earned credits for only 2 calendar quarters in the period ending 3.

Fill ins:

1. 1. 

   MM/DD/YY

2. 2. 

   Earned QC's

3. 3. 

   MM/YY

DISABLED IN QUARTER ALLEGED OR ONSET ESTABLISHED LATER THAN ALLEGED - EARNINGS REQUIREMENT NOT MET - EOD AT OR AFTER AGE 31-(Disability Not Due to Statutory Blindness)

To meet the earnings requirement, a person whose disability began at age 31 or later must meet two provisions of the law. First, he/she needs credit for 20 calendar quarters (5 years) of work during a 40-quarter period (10 years) ending in or after a quarter in which he/she is disabled. And second, he/ she needs credit for one calendar quarter of work for each year after 1950 (or after reaching age 21, if that is later) up to the year his/her disability began. In the second instance, the credits may have been earned at any time.

After carefully studying your records and the medical evidence, we have determined that your condition first prevented you from doing substantial gainful work on 1. However, you do not meet the earnings requirement at that time or at any later time. You need a total of 2 Social Security credits as of this date. Your Social Security record shows that you have 3 credits in the 40-quarter period ending with the calendar quarter you became disabled and (a total of) (at least) 4 credits as of that time.

Fill ins:

1. 1. 

   MM/DD/YY

2. 2. 

   Required quarters

3. 3. 

   Credited quarters

4. 4. 

   Total credited quarters

DIB - NOT DISABLED IN AOD OR AT ANY TIME THEREAFTER UP TO AND INCLUDING LAST QUARTER IN WHICH EARNINGS REQUIREMENT MET - AOD BEFORE AGE 24

To meet the earnings requirement a person whose disability began before age 24 must have Social Security credits for 6 calendar quarters (1 1/2 years) of work during a 12-quarter (3-year) period ending with a quarter before age 24 in which he/she is disabled.

After careful review we have determined that your condition was not disabling within the meaning of the law on 1 (the date you state you became unable to work) or any later date through 2. This is the last day on which you still met the earnings requirement.

Fill ins:

1. 1. 

   Alleged onset date

2. 2. 

   Date last insured

DIB - NOT DISABLED IN AOD OR AT ANY TIME THEREAFTER UP TO AND INCLUDING LAST QUARTER IN WHICH EARNINGS REQUIREMENT MET - AOD BETWEEN AGES 24-31

To meet the earnings requirement, a person whose disability began between the ages 24 and 31 must have Social Security credits for work in at least one-half the calendar quarters in the period beginning with the calendar quarter after age 21 and ending with a quarter before age 31 in which he/she is disabled.

After careful review we have determined that your condition was not disabling within the meaning of the law on 1 (the date you state you became unable to work) or any later date through 2. This is the last day on which you still met the earnings requirement.

Fill ins:

1. 1. 

   Alleged onset date

2. 2. 

   Date last insured

DIB - NOT DISABLED IN AOD OR AT ANY TIME THEREAFTER UP TO AND INCLUDING LAST QUARTER IN WHICH EARNINGS REQUIREMENT MET - AOD AT OR AFTER AGE 31 (Disability Not Due to Statutory Blindness)

To meet the earnings requirement a person whose disability began at age 31 or later must meet two provisions of the law. First, he/she needs credit for 20 calendar quarters (5 years) or work during a 40-quarter period (10 years) ending in or after a quarter in which he/she is disabled. And second, he/ she needs credit for one calendar quarter of work for each year after 1950 (or after reaching age 21, if that is later) up to the year his/her disability began. In the second instance, the credits may have been earned at any time. After careful review we have determined that your condition was not disabling within the meaning of the law on 1 (the date you state you became unable to work) or any later date through 2. This is the last day on which you still met the earnings requirement.

Fill ins:

1. 1. 

   Alleged onset date

2. 2. 

   Date last insured

DIB - NOT DISABLED AT ANY TIME EARNINGS REQUIREMENT MET - AOD BEFORE AGE 24

To meet the earnings requirement a person whose disability began before age 24 must have Social Security credits for 6 calendar quarters (1 1/2 years) of work during a 12 quarter (3 year) period ending with a quarter before age 24 in which he/she is disabled.

After careful review we have determined that your condition was not disabling within the meaning of the law on any date through 1. This is the last day on which you still met the earnings requirement.

Fill in:

1. 1. 

   MM/DD/YY (date last insured)

DIB - NOT DISABLED AT ANY TIME EARNINGS REQUIREMENT MET - AOD BETWEEN THE AGES 24-31

To meet the earnings requirement, a person whose disability began between the ages 24 and 31 must have Social Security credits for work in at least one-half the calendar quarters in the period beginning with the calendar quarter after age 21 and ending with a quarter before age 31 in which he/she is disabled.

After careful review we have determined that your condition was not disabling within the meaning of the law on any date through 1. This is the last day on which you still met the earnings requirement.

Fill in:

1. 1. 

   MM/DD/YY (date last insured)

DIB - NOT DISABLED AT ANY TIME EARNINGS REQUIREMENT MET - AOD AT OR AFTER AGE 31

(Disability Not Due to Statutory Blindness)

To meet the earnings requirement, a person whose disability began at age 31 or later needs to meet two provisions of the law. First, he/she needs credit for 20 calendar quarters (5 years) of work during a 40-quarter period (10 years) ending in or after a quarter in which he/she is disabled. And second, he/she needs credit for one calendar quarter of work for each year after 1950 (or after reaching age 21, if that is later) up to the year his/her disability began. In the second instance, the credits may have been earned at any time.

After careful review we have determined that your condition was not disabling within the meaning of the law on any date through 1. This is the last day on which you still met the earnings requirement.

Fill in:

1. 1. 

   MM/DD/YY (date last insured)

STATUTORY BLINDNESS - NOT DISABLED AT ANY TIME EARNINGS REQUIREMENT MET - AOD 1973 OR LATER

To meet the earnings requirement of the law, a person whose disability is due to statutory blindness must have one Social Security credit for each year elapsing after 1950 (or after age 21, if that is later) up to the year he/ she became disabled. A minimum of 6 credits is needed. The credits may have been earned at any time during the person's employment under Social Security coverage.

After careful review we have determined that your condition was not disabling within the meaning of the law on any date through 1. This is the last date on which you still met the earnings requirement.

Fill in:

1. 1. 

   MM/DD/YY (date last insured)

STATUTORY BLINDNESS (1972 Amendments) NOT INSURED AT AOD - AOD 1973 OR LATER

To meet the earnings requirement of the law, a person whose disability is due to statutory blindness must have one Social Security credit for each year elapsing after 1950 (or after age 21, if that is later) up to the year he/ she became disabled. A minimum of 6 credits is needed. The credits may have been earned at any time during the person's employment under Social Security coverage.

You state that you became disabled on 1. Therefore, you need 2 credits to meet the earnings requirement. Your earnings record shows that you have only 3 credits. Since you do not meet the earnings requirement, it has not been necessary to determine whether or not you are disabled.

Fill ins:

1. 1. 

   Alleged onset date

2. 2. 

   Required QC's

3. 3. 

   Earned QC's

STATUTORY BLINDNESS - NOT DISABLED WHEN EARNINGS REQUIREMENT TEST LAST MET - AOD BEFORE 1973

Before the 1972 amendments to the Social Security Act, a disabled person needed to meet two provisions of the earnings requirement. First he/she needed 20 Social Security credits in the 40 quarter (10 year) period ending in or after the quarter in which he/she became disabled. Second, he/she needed one Social Security credit for each year elapsing after 1950 (or after the attainment of age 21, if that is later) up to the year he/she became disabled. A minimum of 6 credits is needed. The credits may have been earned at any time during the person's employment under Social Security coverage. You last meet this requirement on 1.

Under the 1972 amendments only the second requirement must be met if disability is due to statutory blindness. You last meet the second requirement 2. After careful review we have determined that you were not statutorily blind on or before either of the above two dates.

Fill ins:

1. 1. 

   MM/DD/YY (date last insured)

2. 2. 

   MM/YY (date last fully insured)

CDB - EXPLANATION OF DISABILITY REQUIREMENT

To be considered disabled for Social Security purposes, a claimant for childhood disability benefits must be unable to engage in any substantial gainful activity due to a medical condition which has lasted or can be expected to last for a continuous period of at least 12 months. This impairment must be so severe as to prevent him/her from engaging in substantial gainful work, considering his/her education, and previous training.

Before the 1972 amendments to the Social Security Act, a claimant for childhood disability benefits had to have a disability which began before he/ she was age 18. The 1972 amendments changed this requirement so that a person may qualify if his/her disability began before age 22. The earliest date a person can be entitled under the 1972 law is January 1973.

CDB - DISABILITY MUST START BEFORE AGE 22

A child's disability, as defined by law, must start before age 22. Any medical condition that may have become disabling after attainment of age 22 cannot serve as the basis for qualifying under the disability provisions of the law.

CDB - EXPLANATION OF CLAIMANT'S RIGHTS AFTER CESSATION

A person whose entitlement to childhood disability benefits has ended may again become eligible for them if his/her physical or mental condition again becomes disabling within 7 years after his/he prior entitlement to childhood disability benefits was terminated. If you are again prevented by your condition from doing any kind of substantial gainful work, contact any Social Security office about filing another disability application.

CDB - 7-YEAR PERIOD FOR REENTITLEMENT ENDED BEFORE EOD

To qualify for childhood disability benefits, your condition must have been severe enough to meet the disability requirement of the law within 7 years after your prior entitlement to childhood disability benefits ended. After careful review we have determined that your condition again became disabling on 1. However, the 7 year period in your case ended 2.

Fill ins:

1. 1. 

   Establised onset date

2. 2. 

   Last day of the specified period

CDB - NOT DISABLED AT AOD OR AT ANY TIME WITHIN 7-YEAR PERIOD AFTER END OF PRIOR ENTITLEMENT

To qualify for childhood disability benefits, your condition must have been severe enough to meet the disability requirement of the law within 7 years after your prior entitlement to childhood disability benefits ended. After careful review we have determined that your condition was not severe enough to meet the disability requirement of the law on 1, the date you state you became disabled, or on any later date before 2, the end of the 7-year period in your case.

Fill ins:

1. 1. 

   Alleged onset date

2. 2. 

   Last day of specified period

CDB REENTITLEMENT - NOT DISABLED AT ANY TIME BEFORE 7-YEAR PERIOD ENDED

We have determined that your condition was not severe enough on any date before 1, the date your 7-year period ended.

Fill in:

1. 1. 

   Last day of specified period

CDB REENTITLEMENT — DISABILITY MORE THAN 7 YEARS AFTER PRIOR PERIOD ENDED CANNOT SERVE TO QUALIFY

A person cannot be entitled to childhood disability benefits based on a medical condition which became disabling after the 7-year period ended.

CDB — REENTITLEMENT — ADVICE REGARDING WORSENING OF CONDITION

If your condition gets worse before 1, the date your 7-year period ends, write, call or visit any Social Security office about filing another application for childhood disability benefits.

Fill in:

1. 1. 

   Last day of specified period

FREEZE CESSATION

The law provides that an individual's disability freeze period shall end if the person is able to do substantial gainful work. The law also provides that an individual will have a freeze period for the month disability ends and the following two months. The medical evidence in your case shows that you became able to do substantial gainful work in 1. Accordingly, the last month of your disability freeze is 2.

Fill ins:

1. 1. 

   MM/YY

2. 2. 

   MM/YY

DIB CESSATION — WORK ACTIVITY — TRIAL WORK PERIOD

To be considered disabled for Social Security purposes, a person's impairment must be so severe as to prevent him/her from engaging not only in his/her usual occupation but also in any other kind of substantial gainful work, considering his/her age, education and work experience. Disability benefits end when a person is no longer disabled within the meaning of the law. If a person works while still under a disability, his/her benefit payments are continued during 9 months of work. (These months need not be consecutive, and any work done in a month is counted as a month of work.) Then if it is determined after the 9 months that he/she has demonstrated his/her ability to do substantial gainful work and therefore is no longer disabled, his/her benefits are paid for 3 more months.

FREEZE CESSATION — WORK ACTIVITY

To be considered disabled for Social Security purposes, a person's impairment must be so severe as to prevent him/her from engaging not only in his/her usual occupation but also in any other kind of substantial gainful work, considering his/her age, education and work experience. A disability freeze ends when a person is no longer disabled within the meaning of the law. If a person with a disability freeze returns to work and it is determined that the work is substantial gainful activity, the freeze will be terminated. The law continues the freeze, however, for the month the disability ends and the following two months.

DIB CESSATION — WORK ACTIVITY — NO WAITING PERIOD SERVED

To be considered disabled for Social Security purposes, a person's impairment must be so severe as to prevent him/her from engaging not only in his/her usual occupation but also in any other kind of substantial gainful work, considering his/her age, education and work experience. The law provides that a person who has a severe impairment is allowed a trial work period in which he/she may work in 9 months before a decision is made as to whether his/her benefits should be continued. However, the trial work period does not apply when a person who had a prior period of disability again becomes entitled to disability benefits without serving a waiting period. His /Her disability ends when he/she returns to substantial gainful work. However, benefits will be paid for the month disability ends and two additional months.

CDB CESSATION — WORK ACTIVITY TWP PREVIOUSLY USED

To be considered disabled for Social Security purposes, a childhood disability beneficiary's impairment must be so severe as to prevent him/her from engaging in any substantial gainful activity, considering his/her previous training and education. Disability benefits end when a person is no longer disabled within the meaning of the law. If a childhood disability beneficiary works, his/her benefit payments are continued during 9 months of work. (These months need not be consecutive, and any work done in a month is counted as a month of work.) If at the end of 9 months of work he/she still is not able to engage in substantial gainful activity, his/her benefits will be continued. Should he/she later perform work which is substantial gainful activity, he/she will no longer be considered disabled and his/her disability benefits will be paid for the month disability ends and two additional months.

CDB DENIAL BEFORE AGE 22 — ADVICE REGARDING WORSENING OF CONDITION

If 1 condition gets worse and keeps 2 from doing any substantial gainful work before age 22, please contact any Social Security office about filing another application.

Fill ins:

1. 1. 

   Your/claimant name's

2. 2. 

   You/him/her

DIB OR FREEZE — TERMINATION DUE TO WORK ACTIVITY

The evidence shows that you returned to work on 1. After carefully reviewing all the facts in your case, we still find that the work you have been doing since 2 is “substantial gainful activity” within the meaning of the law. Therefore, the determination to end your disability period with the month of 3 is proper under the law. The disability period already established for you beginning 4 and ending 5 may still be used to your advantage in deciding whether benefits can be paid on your Social Security record in the future, and in figuring the amount of such benefits.

Fill ins:

1. 1. 

   MM/DD/YY

2. 2. 

   MM/DD/YY

3. 3. 

   MM/YY

4. 4. 

   MM/DD/YY

5. 5. 

   MM/DD/YY

DIB OR FREEZE — DISABILITY MUST EXIST WHEN EARNINGS REQUIREMENT IS MET

The inability to engage in any type of substantial gainful activity because of a medical condition must exist at a time when the earnings requirement is met.

DIB OR FREEZE — DISABILITY AFTER EARNINGS REQUIREMENT LAST MET CANNOT SERVE TO QUALIFY

A medical condition which may have become disabling after the earnings requirement is last met cannot serve as a basis for qualifying under the disability provisions of the law.

DIB OR FREEZE — CONDITION NOT SEVERE WHEN EARNINGS REQUIREMENT MET

The evidence does not show that your condition when you met the earnings requirement, affected your ability so much as to keep you from doing some type of gainful work at that time. A medical condition which may have become disabling after the earnings requirement is last met cannot serve as a basis for qualifying under the disability provisions.

DIB OR FREEZE — DISABILITY MUST START AT LEAST 5 MONTHS BEFORE FULL RETIREMENT AGE

The continuous inability to engage in any type of substantial gainful activity must start at least 5 months before the month of reaching FULL RETIREMENT AGE.

DIB OR FREEZE

Any medical condition that may have become disabling less than 5 months before the month of reaching full retirement age cannot serve as the basis for qualifying under the disability provisions of the law.

DIB OR FREEZE — DISABILITY MUST START AT LEAST 5 MONTHS BEFORE THE MONTH OF ATTAINING FULL RETIREMENT AGE AND WHEN EARNINGS REQUIREMENT IS MET

Although you may now be unable to do any work because of your medical condition, that alone does not make you eligible. Under the law, the continuous inability to engage in any type of substantial gainful activity must start at least 5 months before the month of reaching full retirement age and at a time when the earnings requirement is met.

DEFINITION OF SGA

Substantial gainful work is any work generally performed for remuneration or profit, involving the performance of significant physical or mental duties. Work may be considered substantial even if performed part-time. In evaluating a person's work activity, consideration is given to such factors as the nature of the job duties and the skill and experience required to do the job, in addition to his/her earnings. The fact that his/her current work may be different, less complex and less gainful than that which he/she did before his/her disability began does not necessarily mean that he/she will still be considered eligible for benefits under the terms of the law. Under the Social Security regulations when a person's earnings average more than 1, he/she is generally considered to be performing substantial gainful work.

Fill in:

1. 1. 

   Amount (in accordance with DI 10501.015)

DIB OR FREEZE — MEETING EARNINGS REQUIREMENT AFTER ONSET DATE

If a person does not have enough Social Security credits to meet the earnings requirement at the time he/she became disabled, he/she may still satisfy this provision of the law if he/she later obtains the necessary credits.

DIB OR FREEZE — DATE EARNINGS REQUIREMENT WAS LAST MET

Your Social Security record shows that you last met the earnings requirement on 1.

Fill in:

1. 1. 

   MM/YY (date earnings requirement last met)

DIB OR FREEZE — CLAIMANT AGED 62-65 — POSSIBLE ENTITLEMENT TO REDUCED RIB

Although you do not now qualify for disability insurance benefits or the disability “freeze”, our records show you have enough credit for work under Social Security to qualify for retirement benefits. The Social Security Act provides that retired workers may qualify for retirement benefits starting at age 62. If they choose to receive them before they become 65, however, the amount of the benefit is reduced. If you would like further information about this, we suggest you get in touch with any Social Security office. The staff there will be glad to discuss your eligibility with you and help you apply for benefits if you wish to do so.

DIB OR FREEZE — NOT DISABLED — CLAIMANT WILL ATTAIN RETIREMENT AGE BEFORE EARNINGS TEST EXPIRES

As you were previously informed, this determination concerns only your disability application. It is not a decision as to whether benefits will be payable to you at retirement age. If your condition should get worse, and prevent you from doing substantial gainful work, you should get in touch with any Social Security office.

DIB OR FREEZE — DETERMINATION CONCERNS ONLY DISABILITY APPLICATION

As you were previously informed, this determination concerns only your disability application. It is not a decision as to whether benefits will be payable to you at retirement age.

DIB OR FREEZE — GENERAL DESCRIPTION OF EARNINGS REQUIREMENT

To meet the earnings requirement, a person whose disability began before age 24 must have Social Security credits for 6 calendar quarters (1 1/2 years) of work during a 12-quarter (3-year) period ending with a quarter before age 24 in which he/she is disabled. If disability began between the ages of 24 and 31, he/she must have Social Security credits for work in at least one-half the calendar quarters in the period beginning with the calendar quarter after age 21 and ending with a quarter before age 31 in which he/she is disabled. If disability began at age 31 or later, he/she must meet two provisions of the earnings requirement.

First, he/she needs credit for 20 calendar quarters (5 years) of work during a 40-quarter period (10-years) ending in or after a quarter in which he /she is disabled. And second, he/she needs credit for one calendar quarter of work for each year after 1950 (or after reaching age 21, if that is later) up to the year his/her disability began. A minimum of 6 credits is always needed. In the second instance, the credits may have been earned at any time.

DIB OR FREEZE — DESCRIPTION OF 6/12 TEST — DISABILITY BEFORE AGE 24

To meet the earnings requirement a person whose disability began before age 24 must have Social Security credits for 6 calendar quarters (1 1/2 years) of work during a 12-quarter (3-year) period ending with a quarter before age 24 in which he/she is disabled.

DIB OR FREEZE — DESCRIPTION OF EARNINGS REQUIREMENT — DISABILITY BETWEEN THE AGES 24-31

To meet the earnings requirement, a person whose disability began between the ages 24 and 31 must have Social Security credits for work in at least one-half the calendar quarters in the period beginning with the calendar quarter after age 21 and ending with a quarter before age 31 in which he/she is disabled.

DIB OR FREEZE — DESCRIPTION OF EARNINGS REQUIREMENT — DISABILITY AT AGE 31 OR LATER

To meet the earnings requirement, a person whose disability began at age 31 or later must meet two provisions of the law. First, he/she needs credit for 20 calendar quarters (5 years) of work during a 40-quarter period (10 years) ending in or after a quarter in which he/she is disabled. And second, he/ she needs credits for one calendar quarter of work for each year after 1950 (or after reaching age 21, if that is later) up to the year his/her disability began. In the second instance, the credits may have been earned at any time.

DESCRIPTION OF EARNINGS REQUIREMENT — STATUTORY BLINDNESS — AOD 1973 OR LATER

To meet the earnings requirement of the law a person whose disability is due to statutory blindness must have one Social Security credit for each year elapsing after 1950 (or after age 21, if that is later) up to the year he/ she became disabled. A minimum of 6 credits is needed. The credits may have been earned at any time during the person's employment under Social Security coverage.

DESCRIPTION OF OLD AND NEW EARNINGS REQUIREMENT — STATUTORY BLINDNESS

Before the 1972 amendments to the Social Security Act, a disabled person needed to meet two provisions of the earnings requirement. First, he/she needed 20 Social Security credits in the 40 quarter (10 years) period ending in or after the quarter in which he/she became disabled. Second, he/she needed one Social Security credit for each year elapsing after 1950 (or after the attainment of age 21, if that is later) up to the year he/she became disabled. A minimum of 6 credits is needed. The credits may have been earned at any time during the person's employment under Social Security coverage.

Under the 1972 amendments only the second requirement must be met if disability is due to statutory blindness.

DIB ALLOWANCE UNDER 1972 AMENDMENTS — STATUTORY BLINDNESS

Before the 1972 amendments to the Social Security Act, a disabled person needed to meet two provisions of the earnings requirement. First, he/she needed one Social Security credit for each year elapsing after 1950 (or after attainment of age 21, if that is later) up to the year he/she became disabled. Second, he/she needed 20 Social Security credits in the 40 quarter (10 year) period ending in or after the quarter in which he/she became disabled. Although you meet the first provision, your Social Security record shows that you have only 1 credits in the 40 quarter period ending 2, the last day of the calendar quarter in which you became disabled. Therefore, you do not meet the earnings requirement in effect before the 1972 amendments.

Under the 1972 amendments, only the first provision of the law must be met by a person disabled because of statutory blindness. Since you meet this requirement, you are entitled to disability insurance benefits beginning

3. This is the earliest date benefits can be paid under the 1972 amendments to the Social Security Act.

Fill ins:

1. 1. 

   Earned QC's

2. 2. 

   MM/DD/YY

3. 3. 

   MM/YY

FAVORABLE DISABILITY DETERMINATION BY VETERANS ADMINISTRATION — GENERAL

The finding of the Veterans Administration in your case was carefully considered by us along with the rest of the evidence in your file. The Veterans Administration has several disability programs under different laws, and the eligibility requirements differ in each instance. Although similar, the eligibility requirements under the disability programs administered by the Veterans Administration and by the Social Security Administration are not the same. Thus, a person who meets the requirements under a Veterans Administration program does not necessarily qualify under the disability provisions of the Social Security Act. Under our program we must determine whether the requirements contained in the Social Security Act are met.

P&T PENSION AWARD BY VETERANS ADMINISTRATION

The fact that you were found permanently and totally disabled under the Veterans Administration program was carefully considered by us along with the rest of the evidence in your case. A determination by the Veterans Administration that a person is permanently and totally disabled does not necessarily mean that he will qualify under the disability provisions of the Social Security Act. Although there are many similarities, the eligibility requirements under the disability programs administered by the Veterans Administration and by the Social Security Administration are not the same. Under our program we must determine whether the requirements contained in the Social Security Act are met.

DISABILITY BENEFITS BY OTHER THAN VETERANS ADMINISTRATION

The fact that you were found eligible by the (Workmen's Compensation) (Insurance Company) to receive payment because of disability does not necessarily mean that you will be considered disabled under the Social Security Act, since each disability program has its own eligibility requirements. However, this matter has been carefully considered by us along with the rest of the evidence in your case.

PARTIAL ALLOWANCE IN FREEZE CASES (Will ordinarily be typed in form allowance notice)

Although you gave 1 as the date your condition began, the evidence in the file does not support this date. We have determined from the evidence that you first became unable to engage in any substantial gainful activity because of your condition on 2.

Fill ins:

1. 1. 

   Alleged onset date

2. 2. 

   MM/DD/YY

CONCLUSION OF DISABILITY BY ATTENDING PHYSICIAN

In making the decision in this case very careful consideration was given to the conclusion of your attending physician. We value the evidence received from an applicant's attending physician very highly and are most reluctant to reach a decision which is not consistent with his/her judgment. However, in our program an independent determination must be made as to whether the person meets the requirements of the law and the regulations on the basis of the clinical findings of all examining physicians, results of laboratory studies, treatment given and response, as well as the individuals training and experience. Where judgments differ as to the effects of impairments, the decision must be based on the objective evidence presented.

DIB EXPLANATION OF CLAIMANT'S RIGHTS AFTER CESSATION

A person whose disability freeze and disability benefit payments have ended may become eligible for them again if his/her physical or mental condition again prevents him/her from doing substantial gainful work. If you are again prevented by your condition from doing any kind of substantial gainful work, contact any Social Security office about filing another disability application. The disability freeze period already established for you may still be used to your advantage in deciding whether future benefits can be paid on your Social Security record and in figuring the amount of such benefits.

RECONSIDERATION AFFIRMATION LEAD-IN PARAGRAPH

We have reconsidered your claim and find that the previous determination was correct. Your claim was independently reviewed by a physician and disability examiner in the State agency which works with us in making disability determinations. All the evidence in your case has been thoroughly evaluated; this includes the medical evidence and the additional information received since the original decision.

DWB — AFFIRMATION OF DENIAL CESSATION OR ONSET DATE — NON-STATE — NO PHYSICIAN PARTICIPATION

Upon receipt of your request for reconsideration, we had your claim independently reviewed by a special group. All the evidence in your case has been carefully evaluated; this includes the medical evidence and the additional information received since the original decision. On the basis of the evidence and your statements, we find that the previous determination was proper under the law.

DWB — AFFIRMATION OF DENIAL, CESSATION OR ONSET DATE — NON STATE — PHYSICIAN PARTICIPATION

Upon receipt of your request for reconsideration, we had your claim independently reviewed by a specially designated group composed of disability examiners and a physician. All the evidence in your case has been carefully evaluated; this includes the medical evidence and the additional information received since the original decision. On the basis of the evidence and your statements, we find that the previous determination was proper under the law.

DWB — AFFIRMATION OF DENIAL, CESSATION OR ONSET DATE — STATE — PHYSICIAN PARTICIPATION

Upon receipt of your request for reconsideration, we had your claim re-evaluated by a physician and a disability examiner in the State agency which works with us in making disability determinations. All the evidence in your case has been carefully evaluated; this includes the medical evidence and the additional information received since the original decision. This new evaluation was then independently reviewed in the Social Security Administration. On the basis of the evidence, and your statements, it has been determined that the previous determination was proper under the law.

DWB — EXPLANATION OF DISABILITY REQUIREMENT (WIDOW)

A widow may be considered disabled only if she has a physical or mental impairment that is so severe as to ordinarily prevent a person from working. In addition her disability must have lasted or be expected to last for a continuous period of at least 12 months.

DWB - EXPLANATION OF DISABILITY REQUIREMENT (WIDOWER)

A widower may be considered disabled only if he has a physical or mental impairment that is so severe as to ordinarily prevent a person from working. In addition, his disability must have lasted or be expected to last for a continuous period of at least 12 months.

DWB - EXPLANATION OF DISABILITY REQUIREMENT (SURVIVING DIVORCED WIFE)

A surviving divorced wife may be considered disabled only if she has a physical or mental impairment that is so severe as to ordinarily prevent a person from working. In addition, her disability must have lasted or be expected to last for a continuous period of at least 12 months.

DWB - EXPLANATION OF SPECIFIED 7-YEAR PERIOD (WIDOW)

To qualify for disability benefits, a widow (age 50-60) must meet the disability requirement within a specified period of time. Her disability must start not later than 7 years after the death of her husband. Or, for a widow formerly entitled to mother's benefits or disabled widow's benefits, the disability must start not later than 7 years after those benefits ended.

DWB - EXPLANATION OF SPECIFIED 7-YEAR PERIOD (WIDOWER)

To qualify for disability benefits, a dependent widower (age 50-60) must meet the disability requirement within a specified period of time. His disability must start no later than 7 years after the death of his wife. Or, for a widower formerly entitled to disabled widower's benefits who becomes disabled again, the disability must start not later than 7 years after those benefits ended.

DWB - EXPLANATION OF SPECIFIED 7-YEAR PERIOD (SURVIVING DIVORCED WIFE)

To qualify for disability benefits, a surviving divorced wife (age 50-60) must meet the disability requirements within a specified period of time. Her disability must start not later than 7 years after the death of the spouse. Or, for a surviving divorced wife formerly entitled to mother's benefits or disabled widow's benefits, the disability must start not later than 7 years after those benefits ended.

DWB - DATE SPECIFIED PRESCRIBED PERIOD LAST MET

The last day of the prescribed period is 1.

Fill in:

1. 1. 

   MM/DD/YY

DWB-7-YEAR PERIOD ENDED BEFORE EOD

To qualify for disability benefits your condition must be severe enough to meet the disability requirement of the law before the end of the specified 7-year period. After careful review it has been determined that your condition first became disabling on 1. However, the 7-year period in your case ended 2.

Fill ins:

1. 1. 

   Established onset date

2. 2. 

   Last day of specified period

DWB — NOT DISABLED AT AOD OR AT ANY TIME WITHIN 7-YEAR PERIOD

To qualify for disability benefits, your condition must have been severe enough to meet the disability requirements of the law before the end of the specified 7-year period. After careful review it has been determined that your condition was not severe enough to meet the disability requirement of the law on 1 (the date you state you became disabled), or on any later date before 2 (the last day of the specified 7-year period in your case).

Fill ins:

1. 1. 

   Alleged onset date

2. 2. 

   Last day of specified period

DWB CESSATION-MEDICAL IMPROVEMENT — WIDOW

To be considered disabled for Social Security purposes, a widow must have an impairment that is so severe as to ordinarily prevent a person from working. Disability benefits end when this requirement is no longer met. The law continues her benefits, however, for 2 months after the month in which her condition improved to the extent that it no longer prevents her from working.

DWB CESSATION — MEDICAL IMPROVEMENT — WIDOWER

To be considered disabled for Social Security purposes, a widower must have an impairment that is so severe as to ordinarily prevent a person from working. Disability benefits end when this requirement is no longer met. The law continues his benefits, however, for 2 months after the month in which his condition improved to the extent that it no longer prevents him from working.

DWB CESSATION — MEDICAL IMPROVEMENT — SURVIVING

DIVORCED WIFE

To be considered disabled for Social Security purposes, a surviving divorced wife must have an impairment that is so severe as to ordinarily prevent a person from working. Disability benefits end when this requirement is no longer met. The law continues her benefits, however, for 2 months after the month in which her condition improved to the extent that it no longer prevents her from working.

DWB CESSATION WORK ACTIVITY — WIDOW

To be considered disabled for Social Security purposes, a widow must have an impairment that is so severe as to ordinarily prevent a person from working. Disability benefits end when a person is no longer disabled within the meaning of the law. The law continues her benefits, however, for 2 months after the month in which it is determined that she engaged in substantial gainful work.

DWB CESSATION — WORK ACTIVITY — WIDOWER

To be considered disabled for Social Security purposes, a widower must have an impairment that is so severe as to ordinarily prevent a person from working. Disability benefits end when a person is no longer disabled within the meaning of the law. The law continues his benefits, however, for 2 months after the month in which it is determined that he engaged in substantial gainful work.

DWB CESSATION — WORK ACTIVITY — SURVIVING DIVORCED WIFE

To be considered disabled for Social Security purposes, a surviving divorced wife must have an impairment that is so severe as to ordinarily prevent a person from working. Disability benefits end when a person is no longer disabled within the meaning of the law. The law continues her benefits, however, for 2 months after the month in which it is determined that she engaged in substantial gainful work.

DWB — DISABILITY MUST EXIST WHEN SPECIFIED 7-YEAR PERIOD REQUIREMENT MET

A person is eligible for disability benefits if the physical or mental impairment is severe enough to meet the disability requirement of the law on or before the last day of the specified 7-year period.

DWB — DISABILITY AFTER SPECIFIED 7-YEAR PERIOD CANNOT SERVE TO QUALIFY

A medical condition which may have become disabling after the end of the specified 7-year period cannot serve as a basis for qualifying under the disability provisions of the law.

DWB — CONDITION NOT SEVERE WHEN SPECIFIED 7-YEAR REQUIREMENT LAST MET

The evidence does not show that your condition was severe enough to meet the disability requirement of the law before the end of the specified 7-year period in your case. A medical condition which may have become disabling after the end of the 7-year period cannot serve as a basis for qualifying under the disability provisions of the Social Security Act.

DWB — DISABILITY MUST START AT LEAST 6 MONTHS BEFORE AGE 60 — WIDOW

A widow's disability, as defined by law, must start at least 6 full calendar months before the month of reaching age 60.

DWB — DISABILITY THAT STARTS LESS THAN 5 MONTHS BEFORE AGE 60 CANNOT SERVE TO QUALIFY — WIDOW

Any medical condition of a widow that may have become disabling less than 6 full calendar months before the month of reaching age 60 cannot serve as the basis for qualifying under the disability provisions of the law.

DWB — DISABILITY MUST START AT LEAST 6 MONTHS BEFORE AGE 60 — WIDOWER

A widower's disability, as defined by law must start at least 6 full calendar months before the month of reaching age 60.

DWB — DISABILITY THAT STARTS LESS THAN 5 MONTHS BEFORE AGE 60 CANNOT SERVE TO QUALIFY — WIDOWER

Any medical condition of a widower that may have become disabling less than 6 full calendar months before the month of reaching age 60 cannot serve as the basis for qualifying under the disability provisions of the law.

ESCALATED TO RECONSIDERATION LEVEL TITLE II CLAIM

Because you had already requested a reconsideration on your Supplemental Security Income claim when you filed for Social Security disability benefits, we processed your Social Security claim as though you had requested a reconsideration on it as well. This notice is both an initial and a reconsideration determination.

COMBINED INITIAL-RECONSIDERATION DETERMINATION

You asked us to reconsider your 1 claim before we had given you our initial determination on that claim. This notice includes our initial determination and the reconsideration determination on your claim.

Fill in:

1. 1. 

   Type of claim

ESCALATED TITLE II CLAIM — OTHER TITLE II CLAIM AT RECONSIDERATION LEVEL

You asked us to reconsider your 1 claim before we had given you our initial determination on your 2 claim. We processed your 2 claim as if you had requested reconsideration on it. This notice includes our initial and reconsideration determination on your 2 claim.

Fill ins:

1. 1. 

   Claim at reconsideration level

2. 2. 

   Escalated claim

SUSPENSION OF PAYMENT TO CHILD(REN) — W/E EMPLOYED

No benefits can be paid to you for the use of your child(ren) until you send in the Form SSA-1425-SM, Claimant's Report About Work to Social Security Administration.

AUXILIARY BENEFICIARY SUSPENDED BECAUSE “A” WORKED

R

It has been necessary to suspend benefit payments to your 1 since you are working and expect your earnings for the taxable year to be more than $2.

Fill ins:

1. 1. 

   Wife/child/children/family/husband

2. 2. 

   Amount of yearly limit

WORK DEDUCTION FOR THE MONTH IMMEDIATELY PRECEDING THE CURRENT MONTH

If you have returned the benefit payment for 1, the amount deducted will be returned to you.

Fill in:

1. 1. 

   MM/YY

WAIVER OF DEDUCTION OVERPAYMENT-AUXILIARY BENEFICIARIES

We have determined that no deductions will be made for the benefits you received for 1.

Fill in:

1. 1. 

   Name of auxiliary

OVERPAYMENT — CREDIT MONTHS INVOLVED

Our records show that we paid you $1 too much in 2. In an earlier notice, we told you we held back your benefits for 3 to recover 4 amount. But you recently reported to us that you worked during 5. Because of this work, we cannot credit your benefits for 6 toward the amount you owe for 7. Therefore, the amount shown above that you owe is the $8 that you were overpaid in 9.

Fill ins:

1. 1. 

   Amount

2. 2. 

   YY

3. 3. 

   Month(s) withheld

4. 4. 

   This/part of this

5. 5. 

   Month(s) worked

6. 6. 

   Month(s)

7. 7. 

   YY

8. 8. 

   Amount

9. 9. 

   YY

PENALTY DETERMINATION — GOOD CAUSE NOT FOUND — CURRENT PAYMENT STATUS — EXPLANATION OF LATE FILING NOT FURNISHED

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The additional deduction of $1 is being made because you did not submit any evidence or explanation to establish good cause for the late filing of your report.

If you believe that this determination is not correct, you may request that your claim be reexamined. If you want this reconsideration, you must request it not later than 60 days from the date you receive this notice. You may make the request through any Social Security office. If additional evidence is available, you should submit it with your request.

Fill in:

1. 1. 

   Amount

PENALTY DETERMINATION — GOOD CAUSE NOT FOUND — CURRENT PAYMENT STATUS — EXPLANATION OF LATE FILING FURNISHED

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The additional deduction of $1 is required. We considered your reason for late filing but could not establish good cause based on the information you gave us. Generally, good cause will be found only when the late filing results from inconvenient or unfavorable circumstances, confusion regarding Social Security legislation or amendments to the Social Security Act, or misleading information from an official source.

If you believe that this determination is not correct, you may request that your claim be reexamined. If you want this reconsideration, you must request it not later than 60 days from the date you receive this notice. You may make your request through any Social Security office. If additional evidence is available, you should submit it with your request.

Fill in:

1. 1. 

   Amount (penalty deduction)

PENALTY DETERMINATION — GOOD CAUSE NOT FOUND — CONDITIONAL BENEFIT STATUS — EXPLANATION OF LATE FILING NOT FURNISHED

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The additional deduction of $1 will be made when you are again receiving benefits because you did not submit any evidence or explanation to establish that you had good cause for the late filing of your report.

If you believe that this determination is not correct, you may request that your claim be reexamined. If you want this reconsideration, you must request it not later than 60 days from the date you receive this notice. You may make your request through any Social Security office. If additional evidence is available, you should submit it with your request.

Fill in:

1. 1. 

   Amount (penalty deduction)

PENALTY DETERMINATION — GOOD CAUSE NOT FOUND —

CONDITIONAL BENEFIT STATUS — EXPLANATION OF LATE FILING FURNISHED

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The additional deduction of 1 will be made when you are again receiving benefits. We considered your explanation for late filing but could not establish good cause based on the reason you gave us. Generally, good cause will be found only when the late filing results from inconvenient or unfavorable circumstances, confusion regarding Social Security legislation, or amendments to the Social Security Act, or misleading information from an official source.

If you believe that this determination is not correct, you may request that your claim be reexamined. If you want this reconsideration, you must request it not later than 60 days from the date you received this notice. You may make your request through any Social Security office. If additional evidence is available, you should submit it with your request.

Fill in:

1. 1. 

   Amount (penalty deduction)

OVERPAYMENT — 30-DAY ADJUSTMENT PARAGRAPH

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If refund of the amount overpaid is not received within 30 days, an equal amount will be withheld from the benefits you are receiving. If you do not agree with this determination, you may request a reconsideration. If you wish a reconsideration, you must request it not later than 60 days from the date you receive this notice. You should make your request through any Social Security office. If additional evidence is available, you should submit it with your request.

STUDENT ENTITLED — FAMILY MAXIMUM CASE — NO ADJUSTMENT REQUIRED

Due to the entitlement of the student beneficiary, each benefit rate must be reduced to $1 beginning with the month the student became entitled. Since the correct amount of benefits was paid to the family effective that month, no adjustment is necessary.

Fill in:

1. 1. 

   Amount

LATE FILING OF REPORT — BENEFICIARY NOT PREVIOUSLY NOTIFIED OF GOOD CAUSE AND PENALTY — NO CHILD IN-CARE DEDUCTIONS

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Under the law, an additional amount must be withheld when certain events that affect a person's benefits are not reported within a specified time. You should have reported that you did not have a child in your care before you received the benefit payments for the second month following the month in which you no longer had a child in your care. Since you did not file the report within this period, we must withhold an additional $1 from your benefits unless you can establish good cause for late filing. If you believe you had good cause for not filing before 2, please let us know within 30 days. We will then notify you whether your explanation establishes good cause. If so, no additional withholding will be required. If you offer no explanation for late filing, however, we will assume you do not have good cause and will withhold the additional amount. If withholding is necessary, we will notify you and then begin recovery of the amount from any benefits payable. However, if you wish, you may request that the withholding be done over a period of several months rather than having us withhold all of your benefits until the amount is recovered. You should contact any Social Security office within 30 days to make this request.

Fill ins:

1. 1. 

   Amount (penalty deduction)

2. 2. 

   MM/DD/YY (due date for filing an annual report)

LATE FILING OF REPORT — BENEFICIARY NOT PREVIOUSLY NOTIFIED OF GOOD CAUSE AND PENALTY — FOREIGN WORK DEDUCTION

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Under the law, an additional amount must be withheld when certain events that affect a person's benefits are not reported within a specified time. You should have reported that you had worked outside the United States before you received the benefit payment for the second month following the month in which you worked. Since you did not file the report within this period, we must withhold an additional $1 from your benefits unless you can establish good cause for the late filing.

If you believe you had good cause for not filing before 2, please let us know within 30 days. We will then notify you whether your explanation establishes good cause. If so, no additional withholding will be required. If you offer no explanation for late filing, however, we will assume you do not have good cause and will withhold the additional amount.

If withholding is necessary, we will notify you and then begin recovery of the amount from any benefits payable. However, if you wish, you may request that the withholding be done over a period of several months rather than having us withhold all of your benefits until the amount is recovered. You should write us within 30 days to make this request.

Fill ins:

1. 1. 

   Amount (penalty deduction)

2. 2. 

   MM/DD/YY (due date for filing an annual report)

AUXILIARY BENEFICIARY LIVING WITH W/E ALSO OVERPAID — REQUEST FOR REFUND (to be added to W/E's notice)

Based on the above, 1, 2, received $3 more than should have been paid. Refund of this amount should also be made as indicated above.

Fill ins:

1. 1. 

   Your wife/your husband/your child/your children

2. 2. 

   Has/have

3. 3. 

   Amount

AUXILIARY BENEFICIARY LIVING WITH W/E ALSO OVERPAID — ADJUSTMENT POSSIBLE (to be added to W/E's notice)

Based on the above, 1,2, received $2 more than should have been paid. Therefore, it will be necessary to withhold this amount from payments due. 3 next payment will be for $4 which covers payment through 5. This payment will be sent shortly after 6 3rd.

Fill ins:

1. 1. 

   Your wife/your husband/your child/your children

2. 2. 

   Has/have

3. 3. 

   Amount

4. 4. 

   Her/his/their

5. 5. 

   Amount

6. 6. 

   MM/YY

7. 7. 

   Month (spelled out)

SPOUSE (B1), AGE 62 WHEN LAST CHILD TERMINATED

Since you are now age 62, you will be entitled to actuarially reduced spouse's benefits immediately if you so elect. Contact any Social Security office if you wish to file a Certificate of Election.

COMBINED CHECK — CHECK FOR MONTH SUBSEQUENT TO MONTH OF DEATH ADJUSTED AGAINST CURRENT BENEFITS

Since the combined payment(s) issued to you and your spouse for 1,2 not been returned, this amount will be deducted in figuring your next payment. This is in accordance with our previous notice.

Fill ins:

1. 1. 

   MM/YY

2. 2. 

   Has/have

COMBINED CHECK — PRIMARY OR AUXILIARY BENEFICIARY DIES-CHECK FOR MONTH SUBSEQUENT TO MONTH OF DEATH OUTSTANDING

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The combined check issued to you and your spouse for any month after the month of death should not be cashed. The check should be returned to the Treasury Department, Division of Disbursement, located in the city shown on the face of the check. If it is not returned within 60 days, an equal amount will be withheld from benefits payable to you. If you have already returned the check, no further action is necessary on your part.

TO WORKING BENEFICIARY — TEMPORARY DEDUCTIONS —

DEFERRED RESUMPTION BASED ON AGE 72

No benefits are payable for 1 because you expect to earn 2. Beginning with the month you are 72 years old, you can receive monthly payments regardless of how much you earn.

If you stop working for wages of more than $3 monthly as an employee or if you stop performing substantial services as a self-employed person before that time, please notify any Social Security office.

If necessary, final adjustments will be made in your benefit payments when we receive your annual report of earnings.

Fill ins:

1. 1. 

   Month(s) and year

2. 2. 

   Amount or “more than current yearly limit”

3. 3. 

   Amount of yearly limit

COMPLETION OF FORM SSA-21 (OR SSA-22-F4) BY BENEFICIARY (OR PAYEE) WHO HAS MOVED TO FOREIGN COUNTRY

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You should complete the enclosed form and return it to us immediately in the enclosed envelope which requires postage. If we do not receive the completed form within 6 months, benefit payments will be stopped until it is received.

Enclosures: Form SSA-21 and Envelope

CHECK TO DECEASED BENEFICIARY OUTSTANDING — AMOUNT WITHHELD FROM LUMP-SUM AND/OR UNDERPAYMENT AWARD (Modify Where More Than One Check)

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Notice of the death of 1 was not received in time to prevent the mailing of the check for 2. Since this check is still outstanding, we have requested a Social Security office to immediately look into this matter.

Although you are entitled to $3, the outstanding amount of $ 4 is being withheld from your payment. In this way a check for $5 can be sent you now. If it is later determined that you are due the amount withheld or the outstanding check is returned, you will be advised.

Fill ins:

1. 1. 

   Wife/husband

2. 2. 

   MM/YY

3. 3. 

   Amount

4. 4. 

   Amount of outstanding check(s)

5. 5. 

   Amount

“A” RECEIVING “B” OR “B1” BENEFIT IN COMBINED CHECK — “B” OR “B1” BENEFITS SUSPENDED BECAUSE SPOUSE IS WORKING

No further benefits as a 1 may be paid to you at this time because of your spouse's earnings.

Fill in:

1. 1. 

   Wife/husband

LUMP-SUM PAYMENT WIDOW — LUMP-SUM DEATH PAYMENT BEING MADE AS A PMA CHECK WHILE THE INITIAL “D” AWARD WILL BE MADE AS A CMA PAYMENT

A check for $1 which represents the lump-sum death payment will be sent to you in a few days.

Fill in:

1. 1. 

   Amount

COMBINED “AB” CHECK FOR MONTH OF DEATH NEGOTIATED BY SURVIVING SPOUSE UNDER “SUPERENDORSEMENT” PROCESS

Since the combined payment issued to you and your spouse for the month of death was cashed by you, the necessary adjustment will be made in your next payment.

SUSPENSION OF BENEFITS OR PAYMENT DEFERRED BEYOND CURRENT YEAR — COMBINED PAYMENTS — A AND B BENEFICIARIES ENROLLED UNDER SMI (A WORKED)

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As your benefits are being withheld, you will each be billed for the medical insurance premiums. Premiums are payable in advance and your first notices will request all premiums currently due. Thereafter, the notice will request the payment of 3 months' premiums at a time and will be sent to you shortly before the payments are due. Your notices will show the months for which you are to pay and the amount each of you is to pay.

DEFERRED PAYMENT ACTION-TO RECOVER OVERPAYMENT LIABLE FOR PREMIUMS

A part of your Social Security payment that is being withheld to recover amounts that you were incorrectly paid is being used to pay your medical insurance premiums.

DEFERRED PAYMENT ACTION — TO RECOVER OVERPAYMENT REDEFERRED FOR PREMIUMS DUE

This supersedes our previous notice to you. The payment amount and month of payment have been changed to adjust for medical insurance premiums due or paid in advance. Thereafter, 1 month's premium will be deducted from your regular monthly benefits.

ONE-CHECK-ONLY FOLLOWED BY A SUSPENSION — COMBINED CHECK SITUATION (A WORKED) — BOTH “A” AND “B” ENROLLED IN SMI

The medical insurance premiums must be deducted from benefits when possible. Thus, in determining the amount of the payment you are to receive, all premiums due through the month of 1, have been deducted. You will be billed separately for future months. The premiums are payable in advance and your first billing notices will request all premiums currently due. Thereafter, the notices will request the payment of 3 months' premiums at a time and will be sent to you shortly before the payment is due. Your notices will show the months for which you are to pay and the amount each of you is to pay.

Fill in:

1. 1. 

   MM/YY

ONE-CHECK-ONLY FOLLOWED BY A DEFERRED PAYMENT ACTION IN CURRENT YEAR

The medical insurance premiums must be deducted from benefits when possible. Thus, in determining the amount of the first payment you will receive, all premiums due through the month of 1 have been deducted. The next payment will be adjusted for all premiums due or paid in advance. Thereafter, the premium amount will be deducted from your monthly benefit payment.

Fill in:

1. 1. 

   MM/YY

TO SECONDARY BENEFICIARY — MONTHLY BENEFIT PAYABLE LESS THAN $1

The medical insurance premiums of $1 per month are deducted from benefits when possible. After making this deduction the monthly benefit due you is $2. Therefore, we will withhold your monthly payment and send you $3 at the end of this year covering payment for all months 4 through 5.

Fill ins:

1. 1. 

   Monthly premium amount

2. 2. 

   Amount

3. 3. 

   Amount less premiums

4. 4. 

   MM/YY

5. 5. 

   MM/YY

TO SECONDARY BENEFICIARY — MONTHLY BENEFIT PAYABLE IS SAME AS PREMIUM

The medical insurance premiums of $1 per month are deducted from benefits when possible. Since your monthly benefit amount is exactly

$2, we will withhold your monthly benefit payments.

Fill ins:

1. 1. 

   Premium amount

2. 2. 

   Benefit amount

(1)

(2)

TO SECONDARY BENEFICIARY — MONTHLY BENEFIT PAYABLE IS LESS THAN PREMIUM

The medical insurance premiums of $1 per month are deducted from benefits where possible. However, since your benefits are less than $2 we will withhold them and bill you for the difference of $3 per month. Your bill will be received a few days before the payment is due and will be for $4 covering all months 5 through 6.

Fill ins:

1. 1. 

   Monthly premium amount

2. 2. 

   Monthly payment amount

3. 3. 

   Amount

4. 4. 

   Amount

5. 5. 

   MM/YY

6. 6. 

   MM/YY

REPRESENTATIVE PAYEE FOR HI AND/OR SMI ENROLLEE

1 is entitled to 2 effective 3. If you have not yet received a health insurance card for the claimant and Medicare services are needed, this notice may be used to show eligibility for this insurance.

Fill ins:

1. 1. 

   Name of enrollee

2. 2. 

   Hospital insurance/medical insurance/hospital and medical insurance

3. 3. 

   MM/YY or MM/YY and MM/YY respectively

TERMINATION OF MONTHLY BENEFITS AND HI WITH SMI ENTITLEMENT TRANSFERRED TO NEW ACCOUNT

Your hospital insurance coverage under Medicare has been stopped because you are no longer entitled to benefits on this record. A representative from the Social Security office will be in touch with you shortly to help you apply for this coverage on your own record. Your medical insurance is automatically transferred to your own record and you will soon receive a new health insurance card showing your own Social Security number. Please turn in your old health insurance card to any Social Security representative.

EXPLANATION OF MEDICARE PREMIUMS AND DEDUCTIONS UNDER PUBLIC LAW (P.L.) 97-248, SECTION 278

Section 278 of P.L. 97-248 was enacted in recognition of the fact that a significant number of Federal employees and retirees qualify for Medicare coverage either on the basis of their own employment outside the Federal government or on that of their spouse. However, such employees generally do so on the basis of fewer quarters of coverage than other beneficiaries. Consequently, Congress acted on the belief that Federal employees (and the Federal government, as their employer) should bear a more equitable share of the cost of financing the health benefits to which many of them eventually become entitled.

The fact that some Federal workers already qualify for Medical does not disadvantage them with respect to non-Federal workers. Such workers do not stop paying FICA taxes once they become eligible for Social Security benefits and/or Medicare, but continue to pay such taxes until they stop working.

The 1.3 percent tax (which is part of the FICA tax) supports the Medicare hospital insurance trust fund which provides free hospital insurance coverage to beneficiaries such as yourself. The premium you pay is for medical insurance which does not have a tax-supported base. Therefore, you are not paying double for you Medicare coverage.

TO WORKING BENEFICIARY — YEARLY EARNINGS ASSUMED

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Your benefits have been stopped because you told us you are now working. Since you gave no estimate of your earnings for this year, we are assuming that you will earn more than $1. Please notify us if you will not earn over the exempt amount this year. Under the retirement test provisions, no benefits are withheld unless your yearly earnings are more than $2.

Fill ins:

1. 1. 

   Amount of yearly limit

2. 2. 

   Amount of yearly limit

TO WORKING BENEFICIARY — WORK MONTH ASSUMED

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Your benefits have been stopped because you told us that your earnings for this year will be more than $1. We assume that you are now earning over the monthly exempt amount of $2 or that you are active in self-employment. If not, please let us know. Under the retirement test provisions, your benefits are payable for any month that you neither earn over the monthly exempt amount nor are active in self-employment, even though you earn more than $3.

Fill ins:

1. 1. 

   Amount of yearly limit

2. 2. 

   Amount of monthly limit

3. 3. 

   Amount of yearly limit

DISCONTINUANCE OF STATE-BUY-IN DUE TO NON-PAYMENT OF SSI

Because your Supplemental Security Income payments have been stopped, the State will no longer pay your medical insurance premiums.

(To be used for “buy-in” States in conjunction with paragraph 725, when applicable.)

CONTINUANCE OF STATE BUY-IN WHEN SSI PAYMENTS STOPPED

Although your Supplemental Security Income payments have been stopped, your medical insurance premiums will continue to be paid by the State.

(To be used for MAA “buy-in” States in conjunction with paragraph 725, when applicable.)

SSA-1560-U4 RETURN ADDRESS PARAGRAPH, SEPSC

Return original and last copy of completed form SSA-1560-U4 to:

Social Security Administration

Southeastern Program Service Center

Box 10926

Birmingham, Alabama 35202

ADDITIONAL INFORMATION REGARDING THE STUDENT'S BENEFITS

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Student benefits have been stopped because we did not receive the school attendance report which was previously requested. Within a few days you will receive another reporting card. If you are still in full-time attendance, you should complete and return the card to us immediately in the envelope enclosed with the card. If you are not now attending school full-time but intend to resume attendance in the next few months, you should contact any Social Security office as soon as possible.

If you visit the office, please take this notice with you.

DIB TERMINATES-HI/SMI COVERAGE TERMINATES — NO REFUNDS ON REMITTANCES DUE

Since you are no longer entitled to disability benefits, your hospital and medical insurance coverage under Medicare ends the last day of 1. Please destroy your health insurance card after the last day of coverage indicated above.

Fill in:

1. 1. 

   MM/YY (last month Medicare coverage ends)

DIB TERMINATES — HI/SMI COVERAGE TERMINATES — PREMIUM ARREARAGE EXISTS — NO DIB OVERPAYMENT OR UNDERPAYMENT

Your medical insurance premiums have only been paid through 1. Therefore, you should send $2 to pay premiums due through 3. Please make your check or money order payable to Health Care Financial Administration Medicare Insurance, Claim No. 4,” and send it to us in the enclosed envelope.

Enclosure: Envelope

Fill ins:

1. 1. 

   MM/YY (last month medical insurance premium paid)

2. 2. 

   Amount of premiums

3. 3. 

   MM/YY (last month medical insurance premiums due)

4. 4. 

   Claim number (include BIC)

DIB TERMINATES FROM SUSPENSE — DIB UNDERPAYMENT HI-SMI PREMIUMS FOR MONTH FOLLOWING MONTH OF NOTICE TO BE DEDUCTED FROM DIB UNDERPAYMENT — BENEFICIARY NOT BILLED FOR SMI PREMIUMS (To be used in conjunction with paragraph No. 741.)

Since you were last paid for the month of 1, you are due benefits for 2. However, your medical insurance premiums were not deducted from your benefits after that month. You may expect to receive a payment in the amount of $3 from the Treasury Department within a few days. This payment will represent all payments due you less the medical insurance premiums not previously deducted.

Fill ins:

1. 1. 

   MM/YY (last month benefits paid)

2. 2. 

   MM/YY (last month benefits due)

3. 3. 

   Amount of check

DIB TERMINATES FROM SUSPENSE — DIB UNDERPAYMENT FOR MULTIPLE MONTHS — HI/SMI PREMIUMS FOR MONTH FOLLOWING MONTH OF NOTICE TO BE DEDUCTED FROM DIB UNDERPAYMENT — BENEFICIARY NOT BILLED FOR SMI PREMIUMS

Since you were last paid for the month of 1 you are due benefits for 2 through 3. However, your medical insurance premiums were not deducted from your benefits after that month. You may expect to receive a check in the amount of $4 from the Treasury Department within a few days. This check will represent all payments due you less the medical insurance premiums not previously deducted.

Fill ins:

1. 1. 

   MM/YY (last month benefits paid)

2. 2. 

   MM/YY (last month benefits due)

3. 3. 

   MM/YY (last month benefit payment due)

4. 4. 

   Amount of check

DIB TERMINATES FROM SUSPENSE — NO DIB OVERPAYMENTS OR UNDERPAYMENTS BENEFICIARY BILLED FOR SMI PREMIUMS — PREMIUMS ARREARAGE EXISTS (To be used in conjunction with paragraph No. 741.)

According to our records, your medical insurance premiums have only been paid through 1. Therefore, you should send us $2 to pay premiums due through 3. Please make your check or money order payable to “Health Care Financing Administration Medicare Insurance, Claim No. 4,” and send it to us in the enclosed envelope. If you have already sent this payment, please disregard this request.

Enclosure: Envelope

Fill ins:

1. 1. 

   MM/YY (last month medical insurance premiums paid)

2. 2. 

   Amount of premiums due

3. 3. 

   MM/YY (last month medical insurance due)

4. 4. 

   Claim number (include BIC)

DIB TERMINATES FROM SUSPENSE-DIB UNDERPAYMENT-BENEFICIARY BILLED FOR SMI PREMIUM — PREMIUMS ARREARAGE EXISTS WHICH WILL BE DEDUCTED FROM THE NEXT CHECK (To be used in conjunction with paragraph No. 741.)

Since you were last paid for the month of 1, you are due benefits for 2. However, our records show that your medical insurance premiums have only been paid through 3. You may expect to receive a payment for $4 from the Treasury Department within a few days. This payment will represent all payments due you less any unpaid medical insurance premiums. If you have already paid these premiums, that amount will be refunded.

Fill ins:

1. 1. 

   MM/YY (last month benefits paid)

2. 2. 

   MM/YY (last month benefits due)

3. 3. 

   MM/YY (last month medical insurance premiums paid)

4. 4. 

   Amount of check

DIB TERMINATES FROM SUSPENSE — DIB UNDERPAYMENT FOR MULTIPLE MONTHS-BENEFICIARY BILLED FOR SMI PREMIUMS — PREMIUM ARREARAGE EXISTS WHICH WILL BE DEDUCTED FROM THE NEXT CHECK

Since you were last paid for the month of 1, you are due benefits for 2 through 3. However, our records show that your medical insurance premiums have only been paid through 4. You may expect to receive a check for $5 from the Treasury Department within a few days. This check will represent all payments due you less any unpaid medical insurance premiums. If you have already paid these premiums, that amount will be refunded.

Fill ins:

1. 1. 

   MM/YY (last month benefits paid)

2. 2. 

   MM/YY (first month benefit payment due)

3. 3. 

   MM/YY (last month benefit payment due)

4. 4. 

   MM/YY (last month medical insurance premiums paid)

5. 5. 

   Amount of check

DIB TERMINATES — HI COVERAGE TERMINATES — NO SMI COVERAGE

Since you are no longer entitled to disability benefits, your hospital insurance coverage under Medicare ends the last day of 1. Please destroy your health insurance card after the last day of coverage indicated above.

Fill in:

1. 1. 

   MM/YY (last month of hospital insurance coverage)

SMI REFUND PARAGRAPH (To be used in conjunction with paragraph No. 741 when excess premiums will be refunded by SOBER.)

Medical insurance premiums are paid a month in advance. Therefore, any premiums deducted from your final payment apply to a noncoverage month and will be refunded to you.

MEDICARE INELIGIBILITY PARAGRAPH (To be used when beneficiary's DOST and DOCA are prior to the date of entitlement to HI/SMI. It is also to be used when a Future Cessation Data (FCD) equal to or earlier than the date of entitlement to HI/SMI is being established.)

Since you are no longer entitled to disability benefits, you are not eligible for Medicare coverage. Please disregard any previous information you have received or may receive concerning Medicare coverage.

DIB TERMINATES-HI/SMI COVERAGE TERMINATES-PREMIUM ARREARAGE EXISTS ALONG WITH DIB OVERPAYMENT

You should refund the amount shown above within 30 days from the day you get this letter. If you cannot refund the full amount now, you should send a partial payment. You should tell us why you cannot pay the full amount and let us know when you will pay the balance. If you must pay by installments, you should tell us how much you will pay each month and the date you will make each payment. In addition, your medical insurance premiums have not been paid for 1. Therefore, you should also include $2 to pay for premiums due. Please make your check or money order payable to “Social Security Administration, Claim No. 3,” and send it to us in the enclosed envelope.

Enclosure: Refund Envelope

Fill ins:

1. 1. 

   MM/YY (month(s) medical insurance premiums not paid)

2. 2. 

   Amount of premiums due

3. 3. 

   Claim number (include BIC)

DIB TERMINATES — HI/SMI COVERAGE TERMINATES — PREMIUM ARREARAGE EXISTS FOR ONE MONTH ALONG WITH DIB OVERPAYMENT

You should refund the amount shown above within 30 days from the day you get this letter. In addition, you should also include $1 to pay your medical insurance premiums due for 2. Please make your check or money order payable to Social Security Administration, Claim No. 3 and send it to us in the enclosed envelope.

Enclosure: Envelope

Fill ins:

1. 1. 

   Amount of premium due

2. 2. 

   MM/YY (last month medical insurance premium due)

3. 3. 

   Claim number (include BIC)

DIB TERMINATES — HI/SMI COVERAGE TERMINATES — PREMIUM ARREARAGE EXISTS FOR PRIOR MONTHS ALONG WITH DIB OVERPAYMENTS

You should refund the amount shown above within 30 days from the day you get this letter. In addition, you should also include $1 to pay your medical insurance premiums due for 2 through 3. Please make your check or money order payable to “Social Security Administration, Claim No. 4,” and send it to us in the enclosed envelope.

Enclosure: Envelope

Fill ins:

1. 1. 

   Amount of premium due

2. 2. 

   MM/YY (first month medical insurance premium due)

3. 3. 

   MM/YY (last month medical insurance premium due)

4. 4. 

   Claim number (include BIC)

DIB TERMINATED FROM SUSPENSE — DIB OVERPAYMENT EXISTS — BENEFICIARY BILLED FOR SMI PREMIUMS — PREMIUM ARREARAGE EXISTS (To be used in conjunction with paragraph No. 741.)

You should refund the amount shown above within 30 days from the receipt of this letter. If you cannot refund the full amount now, you should send a partial payment. You should tell us why you cannot pay the full amount and let us know when you will pay the balance. If you must pay by installments, you should tell us how much you will pay each month and the date you will make each payment. In addition, our records show that your medical insurance premiums have not been paid for 1. Therefore, you should also include $2 to pay for premiums due. Please make your check or money order payable to “Social Security Administration, Claim No. 3, ” and send it to us in the enclosed envelope. If you already paid the medical insurance premiums, you need only refund the incorrect disability payments.

Enclosure: Refund envelope

Fill ins:

1. 1. 

   MM/YY (last month medical insurance premium due)

2. 2. 

   Amount of premiums

3. 3. 

   Claim number (include BIC)

DIB TERMINATED — EXCESS SMI PREMIUMS USED TO REDUCE OVERPAYMENT

Your medical insurance premiums have been paid through 1, although they were only due through 2. We have deducted the premiums for your noncoverage months from the amount of the overpayment shown above. Therefore, you should refund $3 within 30 days from the day you get this letter. Please make your check or money order payable to “Social Security Administration, Claim No. 4,” and send it to us in the enclosed envelope.

Enclosure: Envelope

Fill ins:

1. 1. 

   MM/YY (last month medical insurance premiums paid)

2. 2. 

   MM/YY (last month medical insurance premiums due)

3. 3. 

   Amount of overpayment

4. 4. 

   Claim number (include BIC)

DIB TERMINATED FROM SUSPENSE — DIB UNDERPAYMENT FOR ONE MONTH — EXCESS PREMIUMS TO BE REFUNDED BY SOBER

Since you were last paid for the month of 1, you are due benefits for 2. You may expect to receive a check for $3 from the Treasury Department within a few days. In addition, your medical insurance premiums have been paid through 4, although they were only due through 5. A check in the amount of $6 which represents a refund of medical insurance premiums paid for noncoverage months will be sent to you shortly.

Fill ins:

1. 1. 

   MM/YY (last month benefit paid)

2. 2. 

   MM/YY (last month benefit due)

3. 3. 

   Amount of check

4. 4. 

   MM/YY (last month medical insurance premium paid)

5. 5. 

   MM/YY (last month medical insurance premiums due)

6. 6. 

   Amount of premium refund

DIB TERMINATED FROM SUSPENSE — DIB UNDERPAYMENT FOR MULTIPLE MONTHS — EXCESS PREMIUMS TO BE REFUNDED BY SOBER

Since you were last paid for the month of 1, you are due benefits for 2 through 3. You may expect to receive a check for $4 from the Treasury Department within a few days. In addition, your medical insurance premiums have been paid through 5, although they were only due through 6. A check in the amount of $7 which represents a refund of medical insurance premiums paid for noncoverage months will be sent to you shortly.

Fill ins:

1. 1. 

   MM/YY (last month benefit paid)

2. 2. 

   MM/YY (first month benefit due)

3. 3. 

   MM/YY (last month benefit due)

4. 4. 

   Amount of check

5. 5. 

   MM/YY (last month medical insurance premium paid)

6. 6. 

   MM/YY (last month medical insurance premium due)

7. 7. 

   Amount of premium refund

REMINDED TO FILE AN ANNUAL REPORT

R

If you earn over $1 in a year, you must file an annual report of earnings for the year. Your earnings for the entire year must be counted, even if your benefits ended during the year.

Fill in:

1. 1. 

   Amount of yearly limit

HI AND SMI COVERAGE FOR RD BENEFICIARIES (DIALYSIS)

Your Medicare coverage is based on a kidney condition for which you are receiving a course of dialysis. If you have participated in self-dialysis training, the 3-month waiting period for entitlement has been waived. The law provides that Medicare coverage will end with either the last day of the 12th month after the month a course of dialysis is discontinued or the 36th month after the month a kidney transplant is received. If your course of dialysis is discontinued or if you receive a kidney transplant, please get in touch with any Social Security office.

Please read the enclosed leaflet for a full explanation of your right to question the determination made on your claim.

Enclosure: SSA-10058

CLOSED PERIOD — ENTITLEMENT/TERMINATION (DIALYSIS)

Your Medicare coverage begins 1 and is based on a kidney condition for which you have received a course of dialysis. If you have participated in self-dialysis training, the 3 month waiting period for entitlement has been waived. The law provides that Medicare coverage will end with the last day of the 12th month after the month a course of dialysis is discontinued. Since your course of dialysis was discontinued in 2, your Medicare coverage ends with the last day of 3.

Please read the enclosed leaflet for a full explanation of your right to question the determination made on your claim. If you again begin a course of dialysis or if you receive a kidney transplant, please get in touch with any Social Security office about filing a new claim for Medicare coverage.

Enclosure: SSA-10058

Fill ins:

1. 1. 

   MM/YY

2. 2. 

   MM/YY

3. 3. 

   MM/YY

HI/SMI TERMINATION DUE TO RD CESSATION (DIALYSIS)

The law provides that Medicare coverage will end with the last day of the 12th month after the month a course of dialysis is discontinued. Since your course of dialysis was discontinued in 1, your Medicare coverage ends with the last day of 2.

Please read the enclosed leaflet for a full explanation of your right to question the determination made on your claim. If you again begin a course of dialysis or if you receive a kidney transplant, please get in touch with any Social Security office about filing a new claim for Medicare coverage.

Enclosure: SSA-10058

Fill ins:

1. 1. 

   MM/YY (1 month prior to the second fill in)

2. 2. 

   MM/YY (1 month prior to DOTH)

EQUITABLE RELIEF — RD TERMINATION CASES — DOTH IS EARLIER THAN DOTS — BENEFICIARY NOT NOTIFIED TIMELY (DIALYSIS)

The law provides that Medicare coverage under the kidney disease provisions of the Social Security Act ends with the last day of the 12th month after the month a course of dialysis is ended. Since you discontinued dialysis in

1, your Medicare entitlement would ordinarily end the last day of 2. However, the work needed to end your coverage was not done on time. Therefore, your medical insurance coverage will remain in effect through the last day of 3. Your hospital insurance coverage ended the last day of

4.

Please read the enclosed leaflet for a full explanation of your right to question the determination made on your claim. If you should again begin a course of dialysis or you receive a kidney transplant, please get in touch with any Social Security office about filing a new claim for Medicare coverage.

Enclosure: SSA-10058

Fill ins:

1. 1. 

   MM/YY (1 year prior to fourth fill-in)

2. 2. 

   MM/YY (1 month prior to DOTH)

3. 3. 

   MM/YY (1 month prior to DOTS)

4. 4. 

   MM/YY (1 month prior to DOTH)

HI AND SMI COVERAGE FOR RD BENEFICIARIES (TRANSPLANT)

Your Medicare coverage is based on a kidney condition for which you have received a kidney transplant. The law provides that this coverage will end with the last day of the 36th month after the month you received the transplant unless you receive another kidney transplant or begin a course of dialysis. Since you received a kidney transplant in 1, your Medicare coverage ends with the last day of 2.

Please read the enclosed leaflet for a full explanation of your right to question the determination made on your claim. If you should receive another kidney transplant or begin a course of dialysis, please get in touch with any Social Security office to insure that you have the proper Medicare coverage.

Enclosure: SSA-10058

Fill ins:

1. 1. 

   MM/YY

2. 2. 

   MM/YY

HI/SMI TERMINATION DUE TO RD CESSATION (TRANSPLANT)

The law provides that Medicare coverage will end with the last day of the 36th month after the month a kidney transplant is received. Since you received a kidney transplant in 1, your Medicare coverage ends with the last day of 2.

Please read the enclosed leaflet for a full explanation of your right to question the determination made on your claim. If you should begin a course of dialysis, or receive another kidney transplant, please get in touch with any Social Security office about filing a new claim for Medicare coverage.

Enclosure: SSA-10058

Fill ins:

1. 1. 

   MM/YY

2. 2. 

   MM/YY

EQUITABLE RELIEF — RD TERMINATION CASES — DOTH IS EARLIER THAN DOTS — BENEFICIARY NOT NOTIFIED TIMELY (TRANSPLANT)

The law provides that Medicare coverage under the kidney disease provisions of the Social Security Act ends with the last day of the 36th month after the month in which a kidney transplant is received. Since you received a kidney transplant in 1, your Medicare coverage would ordinarily end the last day of 2. However, the work needed to end your coverage was not done on time. Therefore, your medical insurance coverage will remain in effect through the last day of 3. Your hospital insurance coverage ended the last day of 4.

Please read the enclosed leaflet for a full explanation of your right to question the determination made on your claim. If you should begin a course of dialysis, or receive another kidney transplant, please get in touch with any Social Security office about filing a new claim for Medicare coverage.

Enclosure: SSA-10058

Fill ins:

1. 1. 

   MM/YY (3 years prior to fourth fill-in)

2. 2. 

   MM/YY (1 month prior to DOTH)

3. 3. 

   MM/YY (1 month prior to DOTS)

4. 4. 

   MM/YY (1 month prior to DOTH)

REFERENCES TO TITLE II CLAIM – DUAL ENTITLEMENT CASE (TITLE II DISCLAIMER PARAGRAPHS) This decision refers only to your claim for Supplemental Security Income payments. You will receive a separate notice if you also filed a claim for Social Security payments.

REFERENCE TO TITLE XVI CLAIM — DUAL ENTITLEMENT CASE (TITLE XVI DISCLAIMER PARAGRAPHS)

This decision refers only to your claim for benefits under the Social Security Disability Insurance Program. If you have not already received a decision about your payments under the Supplemental Security Income Program, you will receive a separate notice shortly.

NH — CAPACITY FOR SGA

We have determined that you are not entitled to Medicare coverage because your condition is not disabling. In deciding this, we considered how much your condition has affected your ability to work. We studied your records, including the medical evidence and your statements, 1 and work experience. If your condition gets worse and keeps you from doing substantial gainful work, write, call or visit any Social Security office about filing another application.

Fill in:

1. 1. 

   And considered your age, education, training.

NH — IMPAIRMENT NOT SEVERE-MEDICAL CONSIDERATION ALONE

We have determined that you are not entitled to Medicare coverage because your condition is not disabling. In deciding this, we considered the medical records, your statements, and how your condition affects your ability to work. If your condition gets worse and keeps you from working, write, call or visit any Social Security office about filing another application.

NH — IMPAIRMENT NOT SEVERE MEDICAL CONSIDERATION ALONE (DATE ER LAST MET)

We have determined that your condition was not disabling on any date through 1, when you last had enough work credits for Medicare coverage. In deciding this, we considered the medical records, your statements, and how your condition affects your ability to work.

Fill in:

1. 1. 

   Date disability I/S expired

NH OR DISABLED CHILD — IMPAIRMENT NOT EXPECTED TO LAST 12 MONTHS

We have determined that you are not entitled to Medicare coverage because your condition is not expected to remain severe enough for 12 months in a row to keep you from working. In deciding this, we considered how much your condition has affected your ability to work. We studied your records, including the medical evidence and your statements. If your condition does not improve as expected, write, call or visit any Social Security office about filing another application.

NH OR DISABLED CHILD — IMPAIRMENT DID NOT LAST 12 MONTHS

We have determined that you are not entitled to Medicare coverage because your condition was not severe enough for 12 months in a row to keep you from working. In deciding this, we considered how much your condition has affected your ability to work. We studied your records, including the medical evidence and your statements. If your condition gets worse, write, call or visit any Social Security office about filing another application. (Omit last sentence for a disabled child.)

DISABLED CHILD — IMPAIRMENT NOT SEVERE — MEDICAL CONSIDERATION ALONE OR CONDITION DISABLING BUT DID NOT EXIST BEFORE AGE 22 (OVER AGE 22)

We have determined that you are not entitled to Medicare coverage because your condition was not disabling before age 22. In deciding this, we considered the medical records, your statements, and how your condition affects your ability to work.

DISABLED CHILD — IMPAIRMENT NOT SEVERE — MEDICAL CONSIDERATION ALONE OR CONDITION DISABLING BUT DID NOT EXIST BEFORE AGE 22 (UNDER AGE 22)

We have determined that you are not entitled to Medicare coverage because your condition is not disabling. In deciding this, we considered the medical evidence and your statements.

DISABLED CHILD — CAPACITY FOR SGA — VOCATIONAL CONSIDERATION (OVER AGE 22)

We have determined that you are not entitled to Medicare because your condition was not disabling before age 22. In reaching this decision, we considered how much your condition has affected your ability to work. We studied your records, including the medical evidence, and considered your education and training.

DISABLED CHILD — CAPACITY FOR SGA — VOCATIONAL CONSIDERATION (UNDER AGE 22)

We have determined that you are not entitled to Medicare coverage because your condition is not disabling. In deciding this, we studied your records, including the medical evidence, and considered your education and training.

NH — NOT DISABLED BEFORE INSURED STATUS EXPIRED

We have determined that you are not entitled to Medicare coverage because your condition was not disabling on any date through 1, when you last had enough work credits for Medicare coverage. In deciding this, we studied your records, including the medical evidence and you statements 2 and work experience in determining how your condition affected your ability to work.

Fill ins:

1. 1. 

   Date disability I/S expired

2. 2. 

   And considered your age, education, training.

NH - NOT INSURED AT ALLEGED ONSET OR LATER

We have determined that you are not entitled to Medicare coverage. The reason you are not entitled is that you do not meet the earnings requirement of the law at the time you state you became disabled or at any later date.

It is important for you to know that we have not made any determination as to whether or not you are disabled within the meaning of the law. Since you do not meet the earnings requirement, it has not been necessary to decide whether you meet the disability requirement. The attached explains the earnings requirements for Medicare for the disabled.

DISABLED WIDOW(ER)'S PRESCRIBED PERIOD EXPIRED BEFORE ALLEGED ONSET

We have determined that you are not entitled to Medicare coverage. To be entitled, your condition must have been disabling within the meaning of the law on or before 1, the date the specified 7-year period ended for you. Since you state that your condition first became disabling on 2, which is after the end of the 7-year period, you are not entitled to Medicare coverage.

Fill ins:

1. 1. 

   Date the P/P expired

2. 2. 

   Alleged onset date

NH - EXPLANATION OF DISABILITY REQUIREMENT

To be considered disabled, a person must be unable to perform any substantial gainful work due to a medical condition which has lasted or can be expected to last for a continuous period of at least 12 months. The impairment must be so severe as to prevent the person from working not only in the person's usual occupation but in any other substantial gainful work considering age, education, training and work experience.

DISABLED WIDOW(ERS) — EXPLANATION OF THE DISABILITY REQUIREMENT AND THE PRESCRIBED PERIOD

Widows, widowers, or surviving divorced spouses between ages 50 and 65 may qualify for Medicare coverage only if they meet the disability requirement of the law within a specified 7-year period. A widow, widower, or surviving divorced spouse may be considered disabled only if a physical or mental impairment exists that is so severe as to ordinarily prevent a person from working. The disability must have lasted or be expected to last for a continuous period of at least 12 months. The person's disability must start not later than 7 years after the death of the wife or husband, or for a widow/widower or surviving divorced spouse, formerly entitled to mother's/father's benefits, not later than 7 years after those benefits ended; or for a person previously entitled to disabled widow's or widower's benefits or Medicare coverage based on disability who became disabled again, not later than 7 years after the prior entitlement ended.

EXPIRATION OF WIDOW(ER)'S PRESCRIBED PERIOD

The last day of your specified period 1, 2.

Fill ins:

1. 1. 

   Is (if the P/P ends on a future date)/was (if the P/P ended on a past date)

2. 2. 

   Date the P/P expires

CHILDHOOD DISABILITY — LAW PARAGRAPH — CLAIMANT AGE 22 OR OVER

A disabled child age 18 or over may be entitled to Medicare coverage at age 20 if the person has a physical or mental condition severe enough to keep the person from doing any substantial gainful work. The condition must have begun before age 22 and lasted, or be expected to last for 12 months in a row.

CHILDHOOD DISABILITY — LAW PARAGRAPH — CLAIMANT NOT YET AGE 22

A disabled child age 18 or over may be entitled to Medicare coverage at age 20 if the person has a physical or mental condition severe enough to keep the person from doing any substantial gainful work. The condition must have begun before age 22 and lasted, or be expected to last for 12 months in a row. If your condition gets worse before age 22, and keeps you from doing any substantial gainful work, write, call or visit any Social Security office about filing another application.

WIDOW(ERS), MOTHER, FATHER OR SURVIVING DIVORCED SPOUSE ENTITLED TO SURVIVORS BENEFITS — CLAIM FILED FOR MEDICARE COVERAGE — EXPLANATION OF DISABILITY REQUIREMENT FOR MEDICARE COVERAGE

A widow, widower, surviving divorced spouse, mother or father entitled to survivors benefits who has a physical or mental condition that is severe enough to ordinarily keep a person from working may be entitled to Medicare coverage if she or he meets certain age requirements. The disability must have lasted or be expected to last for 12 months in a row. The person's disability must not start later than 7 years after the month of death of the spouse or no later than 7 years after prior entitlement to Medicare coverage as a disabled widow(er) ended.

WIDOW(ERS) NOT DISABLED — LACK OF SEVERITY

We have determined that you are not entitled to Medicare coverage because your condition is not severe enough. In deciding this, we considered the medical evidence and your statements. Should your condition get worse before your specified 7-year period ends, write, call or visit your Social Security office about filing another application.

WIDOW(ERS) — NOT DISABLED AT ANY TIME PRESCRIBED PERIOD REQUIREMENT MET FOR DEEMED ENTITLEMENT TO MEDICARE COVERAGE

We have determined that you are not entitled to Medicare coverage because your condition was not disabling on or before 1, the date your specified period of eligibility for benefits ended. In deciding this, we considered the medical evidence and your statements.

Fill in:

1. 1. 

   Last day of prescribed period

NH — DISABLED WIDOW(ERS) OR CHILD — APPLICANT DOES NOT WANT TO CONTINUE DEVELOPMENT OF CLAIM

Since you did not wish to continue the processing of your claim, we determined based on the evidence in file, that you are not entitled to Medicare coverage because your condition is not disabling.

NH — DISABLED WIDOW(ERS) OR CHILD — FAILURE TO FOLLOW PRESCRIBED TREATMENT

We have determined that you are not entitled to Medicare coverage because you are not following the treatment prescribed for you. A person who is unable to do any substantial gainful work may qualify for Medicare coverage, but not if he/she refuses to follow prescribed treatment that could restore his/her ability to work. If you decide to follow the prescribed treatment, or if you have more information showing why you should not, write, call, or visit any Social Security office.

WIDOW(ERS) NOT DISABLED — IMPAIRMENT IS SEVERE AT TIME OF ADJUDICATION BUT NOT EXPECTED TO LAST 12 MONTHS

We have determined that your are not entitled to Medicare coverage because your condition is not expected to remain severe enough for 12 months in a row to keep you from working. In deciding this, we considered the medical evidence and your statements. If your condition does not improve as expected, write, call or visit any Social Security office about filing another application.

WIDOW NOT DISABLED — IMPAIRMENT NO LONGER SEVERE AT TIME OF ADJUDICATION AND DID NOT LAST 12 MONTHS

We have determined that you are not entitled to Medicare coverage because your condition was not severe enough for 12 months in a row to keep you from working. In deciding this, we considered the medical evidence and your statements. If your condition gets worse, write, call or visit any Social Security office about filing another application.

NH — DISABLED WIDOW(ERS) OR CHILD — INSUFFICIENT EVIDENCE FURNISHED

We have determined that you are not entitled to Medicare coverage because the evidence in your file does not show that your condition is disabling. Under the law, the applicant is responsible for furnishing evidence to support a Medicare claim. Although you have been requested to furnish additional evidence, you have not done so.

NH — DISABLED WIDOW(ERS) OR CHILD FAILS OR REFUSES TO SUBMIT TO MEDICAL EXAMINATION

We have determined that you are not entitled to Medicare coverage because the evidence we now have does not show that your condition is disabling. We based our determination on this evidence because you did not take the medical examination we asked you to have at our expense. The examination was needed to fully evaluate your condition.

NH OR WIDOW(ER) HAS DEMONSTRATED ABILITY TO ENGAGE IN SGA DESPITE CONDITION

We have determined that you are not entitled to Medicare coverage because the work you are doing despite your condition shows you are able to do some type of substantial gainful work. We have not made any determination as to whether or not your medical condition is severe enough to meet the disability requirement since you are doing substantial gainful work.

NH DEMONSTRATED ABILITY TO ENGAGE IN SGA DESPITE IMPAIRMENT WITHIN 29 MONTHS BEFORE ATTAINING AGE 65

We have determined that you are not entitled to Medicare coverage. A person who has been disabled for at least 29 full calendar months before reaching age 65 may be eligible for Medicare coverage based on disability. We find that the work which you did despite your condition, before you reached 65, showed that you were not disabled. A medical condition may require reducing one's hours of work or giving up one's regular line of work; but a person may not be entitled to Medicare coverage unless the disability prevents substantial gainful work in any job.

NH — CLAIM FILED AFTER DEATH — NOT DISABLED AT ANY TIME EARNINGS REQUIREMENT MET

1 was not entitled to Medicare coverage because 2 condition was not disabling through 3, when 4 last had enough work credits to qualify for Medicare coverage. In deciding this, we considered how much 2 condition had affected 2 ability to work. We studied 2 records, including the medical evidence and your statements, and considered 2 age, education, training and work experience.

Fill ins:

1. 1. 

   NH's name

2. 2. 

   His/her

3. 3. 

   Date disability I/S last met

4. 4. 

   He/she

NH — CLAIM FILED AFTER DEATH — NOT DISABLED — LACK OF SEVERITY

1 was not entitled to Medicare coverage at the time of 2 death because 2 condition was not severe enough to prevent 3 from doing any substantial gainful work, nor was it the cause of 2 death. In deciding this, we considered how much 2 condition has affected 2 ability to work. We studied 2 records, including the medical evidence and your statements, and considered 2 age, education, training and work experience.

Fill ins:

1. 1. 

   NH's name

2. 2. 

   His/her

3. 3. 

   Him/her

NH — CLAIM FILED AFTER DEATH — NOT DISABLED — IMPAIRMENT IS SEVERE AT TIME OF DEATH BUT WOULD NOT HAVE BEEN EXPECTED TO LAST 12 MONTHS

1 was not entitled to Medicare coverage at the time of 2 death. Although 2 condition was severe at the time of 2 death, it was not expected to last for 12 months in a row, nor was it the cause of 2 death. In deciding this, we considered the medical evidence and statements in file, and considered 2 age, education, training and work experience.

Fill ins:

1. 1. 

   NH's name

2. 2. 

   His/her

NH — CLAIM FILED AFTER DEATH — NOT DISABLED — IMPAIRMENT NO LONGER SEVERE AT TIME OF DEATH AND DID NOT LAST 12 MONTHS

1 was not entitled to Medicare coverage at the time of 2 death because 2 condition was not severe enough for 12 months in a row to keep 3 from working, nor was it the cause of 2 death. In deciding this, we considered how much 2 condition has affected 2 ability to work.

We studied 2 records, including the medical evidence and statements in file, and considered 2 age, education, training and work experience.

Fill ins:

1. 1. 

   NH's name

2. 2. 

   His/her

3. 3. 

   Him/her

NH — CLAIM FILED AFTER DEATH — INSUFFICIENT EVIDENCE

Under the law, the applicant is responsible for furnishing evidence to support his/her Medicare claim. Although you have been requested to furnish additional evidence, you have not done so. Therefore, a determination has been made based on the evidence in file. This evidence does not show that 1 condition was disabling.

Fill in:

1. 1. 

   NH's name

NH — CLAIM FILED AFTER DEATH — DENIAL — APPLICANT DOES NOT WANT TO CONTINUE DEVELOPMENT OF CLAIM

1 was not entitled to Medicare coverage. Since you indicated that you did not wish to continue the processing of 2 claim, a determination has been made based on the evidence in file. This evidencedoes not show 2 condition was disabling.

Fill ins:

1. 1. 

   NH's name

2. 2. 

   His/her

NH — CLAIM FILED AFTER DEATH — DENIAL — IMPAIRMENT WAS SEVERE BUT CLAIMANT FAILED TO FOLLOW PRESCRIBED TREATMENT

1 was not entitled to Medicare coverage because 2 was not following the treatment prescribed for 3 at the time of 4 death. A person who is unable to do any substantial gainful work may qualify for Medicare coverage, but not if 2 refuses to follow prescribed treatment that could restore 4 ability to work.

Fill ins:

1. 1. 

   NH's name

2. 2. 

   He/she

3. 3. 

   Him/her

4. 4. 

   His/Her

NH — CLAIM FILED AFTER DEATH — NOT DISABLED AT ANY TIME EARNINGS REQUIREMENT MET — MEDICAL CONSIDERATION ALONE

1 was not disable through 2, when 3 last had enough work credits for Medicare coverage. In deciding this, we considered medical evidence, your statements, and how the condition affected 4 ability to work.

Fill ins:

1. 1. 

   NH's name

2. 2. 

   Date disability I/S last met

3. 3. 

   He/she

4. 4. 

   His/her

NH — CLAIM FILED AFTER DEATH — NOT DISABLED — LACK OF SEVERITY — MEDICAL CONSIDERATION ALONE

1 was not entitled to Medicare because 2 condition was not severe enough to prevent any substantial gainful work, nor was it the cause of 2 death. In deciding this, we considered medical evidence, your statements, and how the condition affected 2 ability to work.