DI 52170.001 Paper Forms Used to Manually Compute Workers’ Compensation (WC)/Public Disability Benefit (PDB) Offset

The Modernized Claims System (MCS) Earnings Computation (EC) screens and Interactive Computation Facility (ICF) WC programs replaced the paper WC/PDB computation forms.

However, sometimes an ICF program will not be able to compute the WC/PDB offset. In these situations, it may be necessary to manually compute the offset using the paper WC/PDB computation forms.

NOTE: The Workers' Compensation Resource Page website is a good resource for users to find information on WC/PDB case processing.

A. Paper WC/PDB computation forms

1. SSA-2455 (Offset worksheet – Disability insurance benefits)

Use the SSA-2455 to compute the amount of WC/PDB offset and the amounts payable to the worker and auxiliaries. See DI 52170.010 - Form SSA-2455.

2. SSA-3643 (Offset worksheet – Triennial redetermination)

Use the SSA-3643 to compute increases in benefits as a result of a triennial redetermination. See DI 52170.015 - SSA-3643.

3. SSA-2454 (Offset worksheet – Triennial redetermination previously applied)

Use the SSA-2454 to compute the amounts payable to the worker and auxiliaries after offset when the WC/PDB rate changes after a redetermination increase. See DI 52170.020 - SSA-2454.

B. Computation rules

When manually computing WC/PDB offset, consider the computation rules for:

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Rounding in DI 52170.025.
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Estimating Earnings for Years Prior to 1978 in DI 52170.035.
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Applying the pre-1981 notice provision in DI 52170.040.
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Computing offset for phase-out students in DI 52170.045.
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Estimating gift quarters (1951-1977) in DI 52170.050.
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Using calendars (1964-2028) to prorate lump sum settlements in DI 52170.055.

NOTE: See factors in computing WC/PDB offset in DI 52150.001.

C. Disposition of the paper forms

Fax forms that cannot be stored or recorded in the Modernized Claims System (MCS), Modernized SSI Claims System (MSSICS), or the Interactive Computations Facility (ICF) into the Evidence Portal (EP) or the electronic disability (eDIB) folder (eView), as appropriate.

NOTE: If processing center (PC) action is required, the FO will also fax the form to the PC’s Paperless fax number.

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0452170001

DI 52170.001 - Paper Forms Used to Manually Compute Workers’ Compensation (WC)/Public Disability Benefit (PDB) Offset - 03/10/2026
Batch run: 03/10/2026
Rev:03/10/2026

Social Security

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