“The Social Security Administration selected your disability claim for an independent review by the. This means we are reviewing your claim for compliance with the disability requirements of the law.

On behalf of the Social Security Administration (delete this phrase when you using SSA letterhead), this is to notify you that we will make a determination that you did not become disabled until (new onset date) based on the evidence now in your file. Therefore, we are revising the previous determination that your disability began (old onset date). This proposed determination is being made by an agency of the State and not by individuals who furnished the reports on which it is based.”

(Include the information required from DI 27525.005B -- items 4 through 11.)

“Before we make a determination, we are giving you the opportunity to present any additional statements or evidence that you want us to consider. If you believe that the previous date your disability began is correct and should not be changed to a later date, submit any statements or evidence within 10 days from receipt of this notice.”

“If you want to submit a statement or evidence, please send it to us within 10 days to this address: DDS (or OIO if foreign claim), Street, City State ZIP Code.”

“If you don’t write us within 10 days, we will make a formal determination regarding the date your disability began. It is important that you let us know within 10 days if you want to submit a statement or evidence even though you may need more time to submit it. We will inform you (and your auxiliaries, if applicable) in writing when we make a formal determination, and what you must do to appeal if you disagree. If the date your disability began is changed to a later date, your monthly benefit payment may be lowered and you may have been overpaid for months you were not under a disability.”

“This notice is about the benefits you are receiving (or, “your eligibility,” if in suspense status) on the claim of (name of primary beneficiary). Based on the evidence now in file we will make a determination that (name of primary beneficiary) is under a disability as of (new onset date) instead of (old onset date). Accordingly, all benefits being paid (or, “all eligibility,” if auxiliaries are in suspense status) on that claim may be lowered and you may have been overpaid for months (name of primary beneficiary) was not under a disability. The purpose of this notification is to give you an opportunity to present any additional evidence about (primary beneficiary’s) disability or onset date for consideration.

Unless we hear from you within 10 days, we will make a formal determination based on the evidence in file. It is important that you submit any statements or evidence you wish to be considered within 10 days or let us know if more time is needed.”

“If you have additional evidence or wish to submit a statement, please mail it to this address: DDS Name (or OIO if foreign claim), Street, City, State and ZIP Code.”

“We will inform you in writing when we make a formal determination, and what you must do to appeal if you disagree.”