TN 4 (08-12)
CIC002 NO CHILD-IN-CARE (A10)
(Requested)
Caption: If You Disagree With The Decision
We cannot pay (1) benefits for the months of (2) because (3) not taking care of (4) child in those months.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you
Choice 2: beneficiary name
Fill-in (2) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY through MM/CCYY
Fill-in (3) - Systems Generated
Choice 1: you were
Choice 2: he was
Choice 3: she was
Fill-in (4) - Systems Generated
Choice 1: Beneficiary's Name possessive
CIC003 MEDICAL IMPROVEMENT NOT EXPECTED MOTHER'S/FATHER'S BENEFITS (J60)
(Requested)
Caption: Things To Remember
(1) for benefits because doctors and other trained staff decided that (2) a disabled child in (3) care. However, we must review all disability cases. Therefore, we will review (4) child's case in 5 to 7 years. We will send (5) a letter before we start the review. Based on that review, (6) benefits will continue if (7) child is still disabled, but will end if (8) child is no longer disabled.
The decisions we made on (9) claim are based on information (10) gave us. If this information changes, it could affect (11) benefits. For this reason, it is important that (12) changes right away. We have enclosed a pamphlet, "When You Get Social Security Disability
Benefits... What You Need To Know." It will tell (13) what must be reported and how to report. Be sure to read the parts of the pamphlet
about what to do if your child goes to work or if your child's health improves. Also,
remember to tell us if (14) child is no longer in (15) care.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: You qualify
Choice 2: Beneficiary Name qualifies
Fill-in (2) - Systems Generated
Choice 1: you have
Choice 2: he has
Choice 3: she has
Fill-in (3) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (6) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (7) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (8) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (9) - Systems Generated
Choice 1: your
Choice 2: Beneficiary Name possessive
Fill-in (10) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (11) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (12) - Systems Generated
Choice 1: you report
Choice 2: he reports
Choice 3: she reports
Fill-in (13) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (14) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (15) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
CIC004 REEXAMINATION PARAGRAPH SSA-831-U5 CONTAINS A REEXAMINATION DATE (J61)
(Requested)
Caption: Things To Remember
(1) entitled to benefits because (2) a disabled child in (3) care. The doctors and other trained personnel who made the disability decision expect
(4) child's health to improve. Therefore we will review (5) child's case in (6) . We will send (7) a letter before we start the review. Based on that review, (8) benefits will continue if (9) child is still disabled. But they will end if (10) child is no longer disabled.
It is important that (11) changes to us right away. We have enclosed a pamphlet, "When You Get Social Security
Disability Benefits . . . What You Need To Know." It will tell (12) what must be reported and how to report. Be sure to read the parts of the pamphlet
about what to do if (13) child goes to work or if (14) child's health improves. Also remember to tell us if (15) child is no longer in (16) care.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: You are
Choice 2: Beneficiary name plus is
Fill-in (2) - Systems Generated
Choice 1: you have
Choice 2: he has
Choice 3: she has
Fill-in (3) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (6) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (7) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (8) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (9) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (10) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (11) - Systems Generated
Choice 1: you report
Choice 2: he reports
Choice 3: she reports
Fill-in (12) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (13) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (14) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (15) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (16) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
CIC006 NO CHILD-IN-CARE
(Requested)
Caption: None
We changed (1) monthly benefit to (2) beginning (3) . We changed (4) benefit because (5) no longer (6) a child who is entitled to benefits in (7) care.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary's Name Possessive
Choice 2: your
Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Amount
Fill-in (3) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (4) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
Fill-in (5) - Systems Generated
Choice 1: he
Choice 2: she
Choice 3: you
Fill-in (6) - Systems Generated
Choice 1: has
Choice 2: have
Fill-in (7) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
CIC007 CHILD-IN-CARE
(Requested)
Caption: None
We changed (1) monthly benefit to (2) beginning (3) . We changed (4) benefit because (5) now (6) a child who is entitled to benefits in (7) care.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary's Name Possessive
Choice 2: your
Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Amount
Fill-in (3) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (4) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
Fill-in (5) - Systems Generated
Choice 1: he
Choice 2: she
Choice 3: you
Fill-in (6) - Systems Generated
Choice 1: has
Choice 2: have
Fill-in (7) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
CIC008 CHILD-IN-CARE NO LONGER ENTITLED
(Requested)
Caption: None
We changed (1) monthly benefit to (2) beginning (3) . We changed (4) benefit because the child in (5) care is no longer entitled to benefits.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary's Name Possessive
Choice 2: your
Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Amount
Fill-in (3) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (4) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
Fill-in (5) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
CIC010 DISABLED MINOR CHILD ONSET ESTABLISHED LATER THAN ALLEGED SPOUSE'S (MOTHER'S/FATHER'S)
MONTH OF ENTITLEMENT AFFECTED (J63)
(Requested)
Caption: Your Benefits
We found that your child became disabled (1) . This is different from the date given on the application. You are entitled to benefits
because you have a disabled child in your care. Therefore, the date the child became
disabled affects when your benefits start. You are entitled to benefits beginning
(2) .
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: PIC C's DDO in the format Month DD, CCYY
Fill-in (2) - Systems Generated
Choice 1: DOED (for the disabled child in the NOTICE-PIC's care) in the format Month
CCYY
CIC012 FPM CASE-MOTHER/FATHER ENTITLED-DAC IN CARE-3 YEAR REVIEW (J68)
(System Generated)
Caption: Things To Remember
You are entitled to benefits because doctors and other trained staff decided that
your child is disabled under our rules. But, this decision must be reviewed at least
once every 3 years. We will send you or your child a letter before we start the review.
Based on that review, your benefits will continue if your child is still disabled,
but will end if your child is no longer disabled.
Fill-in values:
NONE
CIC013 FPM CASE-MOTHER/FATHER ENTITLED-DAC IN CARE-5 OR 7 YEAR REVIEW (J69)
(System Generated)
Caption: Things To Remember
You qualify for benefits because doctors and other trained staff found that you have
a disabled child in your care. However, we must review all disability cases. Therefore,
we will review your child's case in 5 to 7 years. We will send you a letter before
we start the review. Based on that review, your benefits will continue if your child
is still disabled, but will end if your child is no longer disabled.
Fill-in values:
NONE
CIC014 FPM CASE-MOTHER/FATHER ENTITLED-DAC IN CARE-REVIEW BASED ON MRED (J70)
(System Generated)
Caption: Things To Remember
You are entitled to benefits because you have a disabled child in your care. The doctors
and other trained personnel who made the disability decision expect your child's health
to improve. Therefore, we will review your child's case in (1) . We will send you a letter before we start the review. Based on that review, your
benefits will continue if your child is still disabled. But they will end if your
child is no longer disabled.
Fill-in values:
Fill-in (1)
Choice 1: date of review
CICR11 DISABLED MINOR CHILD GIVEN A CLOSED PERIOD OF DISABILITY SPOUSE'S (MOTHER'S/FATHER'S)
MONTH OF ENTITLEMENT AFFECTED (J64)
(Requested)
Caption: Your Benefits
To be entitled to Social Security Benefits, you must have a child in your care who
is also entitled to benefits. And, that child must be under age 16 or disabled.
We have decided that your child became disabled according to our rules on (1) and was no longer disabled in (2) . Therefore, the first month for which we could pay you benefits is (3) . We could pay you for the month the disability ended and the following 2 months.
This means that the last month for which you were entitled to benefits was (4) .
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: DDO in the format Month DD, CCYY
Fill-in (2) - Requested As A Date In Format Shown Below
Choice 1: EFD associated with T6 minus 3 months for BIC = C shown in Fill-in 1, in
the format Month CCYY
Fill-in (3) - Systems Generated
Choice 1: DOEC in the format Month CCYY
Fill-in (4) - Requested As A Date In Format Shown Below
Choice 1: EFD Date associated with T6 minus 1 month for BIC = C shown in Fill-in 1,
in the format Month CCYY
CICR12 PERIODIC REVIEW PARAGRAPH SPOUSE'S (MOTHER'S/FATHER'S) AWARD NOTICES WHERE A REEXAM
IS NOT INDICATED (J62)
(Requested)
Caption: Things To Remember
You are entitled to benefits because doctors and other trained staff decided that
you child is disabled under our rules. But, this decision must be reviewed at least
once every 3 years. We will send you or your child a letter before we start the review.
Based on that review, your benefits will continue if your child is still disabled,
but will end if your child is no longer disabled.
Fill-in values:
NONE