TN 16 (11-23)
Exhibit A – Return of Service of Summons by Mail
Exhibit B - To Whom It May Concern
Exhibit C – Court Remand Flag
Exhibit D – “Halt Effectuation” Memorandum
Exhibit E – “Resume Effectuation” Memorandum
Exhibit F – 95-Day Effectuation Delay Letter
Exhibit A - Return of Service of Summons by Mail
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Service of the Summons and Complaint was made by
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DATE
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NAME OF SERVER (Print)
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TITLE
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Check one box below to indicate appropriate method of service
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[ ] Served personally upon the defendant. Place where
served:
_________________________________________________________________
[ ] Left copies thereof at the defendant's dwelling house or usual place of abode
with a person of suitable age and discretion then residing therein.
Name of person with whom the summons and complaint were left:
________________________________________________________________
[ ] Returned unexecuted: _________________________________________
__________________________________________________________________
__________________________________________________________________
_________________________________________________________________
[ ] Other (specify): _______________________________________________
__________________________________________________________________
__________________________________________________________________
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STATEMENT OF SERVICE FEES
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TRAVEL
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SERVICES
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TOTAL
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DECLARATION OF SERVER
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I declare under penalty of perjury under the laws of the United States of America
that the foregoing information contained in the Return of Service and Statement of
Service Fees is true and correct.
Executed on______________________ __________________________
Date
Signature of Server
___________________________
Address of Server
EXHIBIT B - TO WHOM IT MAY CONCERN:
The following Social Security benefits were certified for payment to (name of
payee)
under Social Security claim number ___ ___ ___ - ___ ___ - ___ ___ ___ ___
for the period (mm/yy) to (mm/yy).
| Approximate Date of Payments |
Payment Amounts |
Medicare Premiums |
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January 2, 1996
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$ 798.00
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$ 42.50
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February 2, 1996
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798.00
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42.50
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March 1, 1996
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798.00
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42.50
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April 3, 1996
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798.00
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42.50
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May 3, 1996
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798.00
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42.50
|
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June 3, 1996
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798.00
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42.50
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August 2, 1996
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798.00
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42.50
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September 3, 1996
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798.00
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42.50
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October 1, 1996
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798.00
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42.50
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November 1, 1996
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798.00
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42.50
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December 3, 1996
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798.00
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42.50
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January 3, 1997
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821.00
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43.80
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February 3, 1997
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821.00
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43.80
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March 3, 1997
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821.00
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43.80
|
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April 3, 1997
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821.00
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43.80
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May 2, 1997
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821.00
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43.80
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June 3, 1997
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821.00
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43.80
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July 3, 1997
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821.00
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43.80
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August 1, 1997
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821.00
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43.80
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September 3, 1997
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821.00
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43.80
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October 3, 1997
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821.00
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43.80
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November 3, 1997
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821.00
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43.80
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December 3, 1997
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821.00
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43.80
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EXHIBIT C - COURT REMAND FLAG
COURT REMAND FLAG
(OAO Completes Items 1-4)
1. Jurisdiction ____________________ Date of Court Remand Order ______________
2. Time Limit? (Circle one) YES NO
If YES, completed action required (specify) ________________________________
DUE DATE __ __ / __ __/ __ __ __ __ Hearing Office Notified? YES NO
3. Delayed Case? (Circle one) YES NO
4. Does this jurisdiction* require a certified record even if the decision is fully
favorable.
(Circle one) YES NO
*Idaho, Maine, New Hampshire, West Virginia, Wisconsin,
E.D. North Carolina, E.D. Washington
IDENTIFICATION OF DECISION
(Decision Writer Completes Items 5, 6, and
7)
5. Claim type _________________________ (e.g., SSDC, DIWC, DIWW, etc.)
6. Nature of Decision(s) Route to:
___ Unfavorable Decision
Social Security Administration
Office of Appellate Operations
6401
Security Blvd
Baltimore, MD 21235-6401
___ Fully Favorable Same as non-court
case
_ ___ Partially Favorable Same as non-court case
7a. Is the decision fully favorable, AND the answer to item 4 above “YES”
YES NO
7b. Is the decision partially favorable?
YES NO
If either 7a or 7b is YES, the hearing office must enter the following remark on the
route slip: “After effectuation, send the file (and hearing cassette, if any) to the
Social Security Administration, Office of Appellate Operations, 6401 Security Blvd,
Baltimore, MD 21235-6401
Call your Regional Office if you have any questions about routing a court remand case.
EXHIBIT D – “HALT EFFECTUATION” MEMORANDUM
Date :
From : Director, Office of Acquiescence and Litigation Coordination,
Office of Disability Programs
Subject: Potential Appeal (Case name, SSN) — ACTION
To :
This is to confirm a conversation in the above-referenced case. SSA may recommend
an appeal of the court's decision. Please complete all development, but do not authorize or make any payments on this record until you receive further instructions
from this office.
If you have any questions, please contact __________________________ , at
_______________________________.
EXHIBIT E – “RESUME EFFECTUATION” MEMORANDUM
Date :
From : Director, Office of Acquiescence and Litigation Coordination
Office of Disability Programs
Subject: Resume Effectuation of Payments for (Name, SSN )—ACTION
To :
This is to confirm a conversation in the above-referenced case. The government has
decided no appeal of the court's order in this case is warranted. Please effectuate payments on this
record immediately.
If you have any questions, please contact __________________________ , at
_______________________________.
EXHIBIT F – 95-DAY EFFECTUATION DELAY LETTER
SOCIAL SECURITY
The Social Security Administration is processing your claim because of an order issued
by a federal court. It is the Social Security Administration's policy to process court
orders as quickly as possible. Because (insert reason payment is being delayed) we have not yet been able to finish all the steps necessary to pay your claim.
We are making every effort to complete your claim as quickly as possible. We will
advise you soon about any payment due you.
If you have questions you may want to call our toll-free number, 1-800-772-1213, or
your local Social Security office at (include telephone number of local office). Our representatives there will be glad to help you. For general information about
the Social Security program, you can access our Web site on the Internet at http://www.ssa.gov . If you visit your local office to discuss this matter, please take this notice
with you.
(If claimant has attorney representative add: “A copy of this notice is being sent
you your attorney.”)
(SSA-8165)