Check the ODO block if the current claim is being transmitted to ODO. If the claim is being transmitted to the PSC, line through ODO and enter PSC/DPB. Check the “OIO” block if the claimant's address is outside the 50 States, District of Columbia, Puerto Rico, American Samoa, Guam, the Northern Mariana Islands and U.S. Virgin Islands. Check the “DDS” block in all other cases.

For cases to be forwarded to a Disability Determination Services (DDS), show the appropriate 3 digit DDS code listed in the Detailed Office/Organization Resource System (DOORS).

Show the actual month, day, and year of filing of the current application. The only exception to this rule is when an earlier filing date (i.e., protective filing) is established based on a written or telephone request for benefits, see Protective Filing (GN 00204.010), in which case show the earlier date. If there are two or more current applications, show the earliest filing date.

Enter the Social Security Number (SSN) of the individual on whose E/R the benefits are being claimed. This is the primary SSN even though the individual has multiple SSNs and may have used another SSN at the field office (FO) interview or when he/she filed a prior claim. In CDB and DWB (including Medicare only) claims, also show the claim symbol e.g., HC1, W, E, and D. In End Stage Renal Disease (ESRD) claims, enter the spouse's or parent's SSN if the ESRD claimant is receiving benefits on that SSN. In all other ESRD cases, use the claimant's SSN.

Enter the name and mailing address of the claimant. If a proper applicant, see Proper Applicant - GN 00204.003, has filed on behalf of the claimant, enter the applicant's name for the appropriate legend followed by the word “for”, and then the claimant's name, and applicant's mailing address. Enter names exactly as shown on the claim. If two or more proper applicants have filed on behalf of the claimant the name and address entries for the applicant should be for whichever of the applicants is the preferred payee. See Payee Preference Lists - GN 00502.105.

In situations involving a disability application filed after the claimant's death, show the applicant's name followed by “On behalf of (claimant's name) Dec'd.” If the SSA-831 is for the deceased parent of a child filing on a grandparent's ER, enter the name only of the disabled parent.

Number Holder’s (NH's) Name, complete for CDB and DWB claims involving a DIB NH. This item is not completed in DIB Cases.

Check the appropriate block as follows:

Check the appropriate block.

Show the established month, day, and year of birth (e.g., 3/17/49). If the date of birth has not been established, use the DOB by which the claimant is the oldest.

Check the “PD” block when the last determination for the same type of benefit was a denial. Check the “PT” block when the last determination for the same type of benefit was a termination of entitlement. Include the prior disability file, if in the FO or required as shown in Impairment-Related Work Expenses (IRWE) Paid 12/01/80, and Later (DI 11010.180) and complete information on a SSA-3367 (Disability Report-Field Office), Item 7.

Document the following:

• •

  Gender

• •

  Phone number

• •

  Capability Development Needed

• •

  Study List Code

• •

  Litigation Code

For instructions on documenting prisoner cases, see DI 10105.094.

Complete items 11A and 11B (the blocks do not need to be checked) with code 01 in 11A and an impairment number from Field Office (FO) Procedures for Processing Presumptive Disability (PD) AND Presumptive Blindness (PB) Cases DI 11055.240D.1.a. in 11B.

Enter the City, State, ZIP code and FO code, as well as the local address (street number and name or P.O. Box), in all cases.

The FO employee who transmits the case should enter his/her name and title in this block.

Enter the date the file is transmitted to the DDS, ODO, DPB or OIO.

Enter “None established” for Substantial Gainful Activity (SGA) denials.

Check this block when the insured status or prescribed period requirement continues to be met through the date of the current determination.

Check this block when the prescribed period ended or the insured status requirement was last met prior to the date of the current determination. Enter the date the insured status or prescribed period requirement is last met.

Complete this item for CDB cases.

Complete this item in DIB, DWB, DWB Medicare Only, Freeze and CDB cases. Show both the claimant's occupation and the industry. Enter the 2-digit occupation code from the list below which most closely approximates the determined occupation. Follow the code with a dash and then enter the approximate 2-digit industry code from the list below most closely approximating the determined industry. If a CDB has never had an occupation, enter “NONE.”

Occupation Codes (Item 20 of SSA-831)

PROFESSIONAL TECHNICAL, AND MANAGERIAL OCCUPATIONS

CLERICAL AND SALES OCCUPATIONS

SERVICE OCCUPATIONS

AGRICULTURAL, FISHERY, FORESTRY, AND RELATED OCCUPATIONS

PROCESSING OCCUPATIONS

MACHINE TRADES OCCUPATIONS

BENCHWORK OCCUPATIONS

STRUCTURAL WORK OCCUPATIONS

MISCELLANEOUS OCCUPATIONS

Industry Codes (Item 20 of SSA-831)

AGRICULTURE, FORESTRY, FISHING, HUNTING AND TRAPPING

MINING AND COAL AND GAS EXTRACTION (INCLUDING URANIUM)

CONSTRUCTION

MANUFACTURING

NONMANUFACTURING

Show in the “Occ. Yrs.” block the number of years that the claimant worked in the principal occupation, if determined, or, if not determined, in the longest full-time occupation. When such information is not reflected on the SSA-3368 (Disability Report - Adult) and/or SSA-3369 (Work History Report), it may appear elsewhere in the file. Where there are broken periods of employment in that occupation, determine the total number of years the claimant was employed or available for employment in the shown occupation. If the number of occupational years is unknown, enter “unk.”

In the “Ed. Yrs.” block, enter the highest grade of school completed by the individual, including any part-time and night courses. Use “12th grade” to indicate completion of high school, “13th grade” for one year of college, etc. Also, enter the type of school and number of years completed in specialized schools, such as nursing school, accounting school or ungraded vocational school. If the number of years of education is unknown, enter “unk.”

See Disability-Related List Codes (Active) - DI 33530.005.

See Background - DI 26516.001.

Complete this item in accordance with Preparing Notices in Disability Claims - DI 11010.345.

The claims representative signs his or her name.

Enter the date the SSA-831 is signed.

If a DIB claim is transmitted to the DDS prior to FO receipt of the ER, enter “DLI (date).” Also, if the DIB claimant alleges a visual impairment and is fully insured only, enter the remark “Fully insured only.”

NOTE: Do not forward initial materials for a disability determination if there is any doubt as to whether the claimant meets a non-disability requirement (e.g., insured status or prescribed period requirement). In cases delayed pending resolution of a non-disability requirement, do not forward the application, E/R or other non-disability material to the DDS. Send only the material pertinent to the disability determination when the issues are resolved.

If concurrent DWB-DIB claims are being processed, cross refer as follows; enter on the SSA-831 (Disability Determination and Transmittal) “Also filing as disabled widow(er) on (SSN)”, and enter on the DWB SSA-831 “Also filing for DIB on (SSN).”

If a DWB claimant is already receiving DIB, enter “Widow(er) entitled to DIB on (SSN).”

If either of the following situations is applicable, enter the appropriate remark: “Title XVI initial (or reconsideration) filed (date), pending in DDS.” or “Prior Title XVI denial (or cessation) (date).”

In cases involving a disabled claimant and a disabled child auxiliary living in different jurisdictions, cross-refer each SSA-831 by entering “(CDB or DIB) application for (name of claimant or disabled child) forwarded to (DDS, ODO, DPB, DRS, or OIO) on (date).”

When a disabled child has disability insured status on his or her own SSN and has filed disability application in addition to the auxiliary claim, enter on the SSA-831 associated with the DIB claim, “See (parent's name) (parent's SSN) for CDB claim.”

If the claim is a no waiting period case, enter “no waiting period.” (See When No Waiting Period Is Required DI 10105.075 for the definition of a no waiting period case.)

Enter “Alleges visual impairment” when a visual impairment is alleged.

Enter “Claimant does not want to pursue claim” if the claimant does not want to complete development (Claimant Cannot be Contacted. Whereabouts Unknown or Claimant Does not Wish to Pursue Title II Claim - DI 11010.045). In an ODO case, enter “No medical evidence for reasons beyond claimant's control” if the claimant is unable to proceed with the claim.

In cases involving a disability application filed after the claimant's death, show the date of death; i.e., “Date of death (date).”

If the claimant filed a RIB or non-disability survivor's claim, enter “Application for RIB or survivors benefits.”

If a foreign language notice is required, enter “foreign language notice required,” using the appropriate language in place of “foreign language.”

See details in Procedure for the Braille Special Notice Option for the Blind or Visually Impaired (NL 01001.120).

Enter “Homeless - no permanent address” when the claim is for a homeless individual.

When a subsequent Title II disability claim is being transmitted in accordance with Initial Title II Technical Denials and Claims Not Requiring a Disability Determination - DI 11010.075, enter: “Prior claim attached. Review for application of res judicata." If the prior claim could not be located, enter: “Prior claim not located - Substantive determination necessary.”

Indicate the reason for the limitation and claim type.

Public Law 106-1554 amended section 226 of the Social Security Act to waive the 24 month waiting period for Medicare coverage for disabled individuals medically determined to have ALS. The date of Medicare entitlement is the date of entitlement to disability insurance benefits or 07/01, whichever is later. This applies to new and current claims.