NL 00708: Letters and Paragraphs For Title II and Title XVIII
A. Claims Paragraphs
AGE
DEPENDENCY REQUIREMENTS
RELATIONSHIP
WAGES, SELF-EMPLOYMENT, MILITARY SERVICE AND RAILROAD EMPLOYMENT
DIB APPLICATION FILED AFTER DEATH OF NUMBER HOLDER
CHILDHOOD DISABILITY
DIB NOT DISABLED
RIB/DIB (RIB or DIB)
DWB WIDOW(ER)
LUMP-SUM DISALLOWANCES
B. Failure to Meet Earnings (or Prescribed Period) Requirement
| Paragraph | Fill-ins | |
|---|---|---|
| DIB-NH Deceased and Not Insured at Alleged Onset or Later | 318 | 2 |
| General Description of Earnings Requirement | 320.1 | None |
| Description of 6/12 Test—Disability Before Age 24 | 320.2 | None |
| Description of Earnings Requirement—Disability Between the Ages 24-31 | 320.3 | None |
| Description of Earnings Requirement—Disability at Age 31 or Later—Not Due to Statutory Blindness | 320.4 | None |
| Description of Fully Insured Test—Disability Due to Statutory Blindness | 320.5 | None |
| DWB—Explanation of the Disability Requirement and the Prescribed Period | 320.6 | None |
| DIB Denial—Earnings Requirement Not Met—No QC at Any Time | 322.2 | None |
| DIB Denial—AOD Before Age 24—6/12 Test Not Met in AQD or Later | 322.3 | 2 |
| DIB Denial—AOD Between Ages 24-31—Earnings Requirement Not Met in AOD or Later | 322.4 | 2 |
| DIB Denial—AOD at Early Age—Earnings Requirement Not Met | 322.6 | None |
| DIB Denial—Earnings Requirement Not Met in AOD (AOD 1973 or Later) Disability Due to Statutory Blindness | 322.7 | 2 |
| DWB Denial—Disabled When Alleged or Onset Established Later Than Alleged—Prescribed Period Requirement Not Met | 323.1 | 2 |
| DIB Denial—Disabled in Quarter Alleged or Onset Established Later Than Alleged—Disabled Before Age 24—6/12 Test Not Met | 323.2 | 3 |
| DIB Denial—Disabled in Quarter Alleged or Onset Established Later Than Alleged—Disabled Between Ages 24-31—Earnings Requirement Not Met | 323.3 | 2 |
| DIB Denial—Disabled in Quarter Alleged or Onset Established Later Than Alleged—Disabled Age 31 or Later—Earnings Requirement Not Met—Disability Not Due to Statutory Blindness | 323.4 | 4 |
| DIB Denial—Disabled in Quarter Alleged or Onset Established Later Than Alleged—Disability Due to Statutory Blindness—Earnings Requirement Not Met—EOD 1/73 or Later | 323.5 | 3 |
| DIB—Not Disabled Before Insured Status Expired | 324(A) | 1 |
C. Work and Earnings Deduction
| Paragraph | Fill-ins | |
|---|---|---|
| Suspension of Payment to Child(ren)—W/E Employed | 600 | None |
| Auxiliary Beneficiary Suspended Because “A” Worked | 608 R | 2 |
| Work Deduction for the Month Immediately Preceding the Current Month | 609 | 1 |
| Overpayment-Credit Months Involved | 633 | 9 |
| Penalty Determination—Good Cause Not Found—Current Payment Status—Explanation of Late Filing Not Furnished | 635(A) R | 1 |
| Penalty Determination—Good Cause Not Found—Current Payment Status—Explanation of Late Filing Furnished | 635(B) R | 1 |
| Penalty Determination—Good Cause Not Found—Conditional Benefit Status—Explanation of Late Filing Not Furnished | 636(A) R | 1 |
| Penalty Determination—Good Cause Not Found—Conditional Benefit Status—Explanation of Late Filing Furnished | 636(B) R | 1 |
| Late Filing of Report—Beneficiary Not Previously Notified of Good Cause and Penalty—Foreign Work Deduction | 660 R | 2 |
| To Working Beneficiary—Temporary Deductions—Deferred Resumption Based on Age 70 | 683 | 3 |
| “A” Receiving “B” or “B1” Benefit in Combined Check—“B” or “B1” Benefits Suspended Because Spouse is Working | 686 | 1 |
| To Working Beneficiary—Yearly Earnings Assumed | 721 R | 2 |
| To Working Beneficiary—Work Month Assumed | 722 R | 3 |
| Reminded to File an Annual Report | 778 R | 1 |
| Payment Based on Age 70 Attainment | 779 R | None |
D. Awards
| Paragraph | Fill-ins | |
|---|---|---|
| Proceeds of Check for Month of Death or Later and Overpayment Accrued Prior to Death Withheld From Lump Sum | 59(B) | 4 |
| To Applicant—Part of Lump Sum Authorized to be Paid to Funeral Home, Part Paid to Applicant | 67 | 1 |
| Primary Benefits Based on Transitionally Insured Status | 73 | 1 |
| Underpayment Award in Addition to Other Award (Benefit to Wife Included With Payment) | 407(A) | None |
| Increase in Rate—Benefits Payable at Both Rates | 430 | 2 |
| Decrease in Rate—Benefits Payable at Both Rates | 432 | 2 |
| Check to Deceased Beneficiary Outstanding—Amount Withheld From Lump Sum and /or Underpayment Award (Modify Where More Than One Check) | 685 R | 5 |
| Lump Sum Payment Widow—Lump Sum Death Payment Being Made as a PMA Check While the Initial “D” Award Will be Made as a CMA Payment | 687 | 1 |
| Combined “AB” Check for Month of Death Negotiated by Surviving Spouse Under “Superendorsement” Process | 691 | None |
| Lead-In Paragraph for Award Notices | 950 | 1 |
| Former Representative Payee Notified Student Benefits Will be Paid Directly to Student | 958 R | None |
E. Suspension/Offset
| Paragraph | Fill-ins | |
|---|---|---|
| To Former Wife—No Child in Her Care—Payment Suspended | 18(a) | None |
| Currently Suspended With Some Benefits Payable | 44 | 1 |
| Wife Under 62 and Widow Under 60 With Payee—Child No Longer Entitled | 52(C) | 2 |
| SSI Offset overpayment—Offset Period is Same as Retroactive (PMS) Period | 80 | 4 |
| SSI Offset Overpayment—Offset Period Less Than Retroactive (PMA) Period | 81 | 5 |
| Additional Information Regarding the Student's Benefits | 733 R | None |
F. Reinstatement
| Paragraph | Fill-ins | |
|---|---|---|
| Completion of Form SSA-21 (or SSA-22-F4) by Beneficiary (or Payee of Beneficiary) Who Has Moved to Foreign Country | 684 | None |
G. Adjustment
| Paragraph | Fill-ins | |
|---|---|---|
| E or D Conversion Affecting Other Survivors | 10 | None |
| Benefits Now Payable With Some Months Suspended | 44(A) | 3 |
| Previous Action Revised Upon Reconsideration (For Residents Other Than U.S., Guam, American Samoa, Philippines, Canada, Mexico, Western Samoa and British Virgin Islands) | 136(D) F | None |
| Previous Action Revised Upon Reconsideration After Implied Request (For Residents Other Than U.S., Guam, American Samoa, Philippines, Canada, Mexico, Western Samoa and British Virgin Islands) | 136(E) F | None |
| Program Service Center Reconsiders Case Remanded Prior to a Hearing | 137 | None |
| Hearing Paragraph for Reconsidered Disability Cases Hearing Paragraph Used in Reconsideration Notice | 140 | None |
| Where Claim is Denied on the Basis of Res Judicata | 140(A) | None |
| Increase in Rate—Benefits Payable at Both Rates | 430 | 2 |
| Decrease in Rate—Benefits Payable at Both Rates | 432 | 2 |
| Change in Benefit Rate | 439 | None |
| Change in Benefit Rate—Increase or Decrease in Benefits for Retroactive Period | 439(A) R | None |
| Beneficiary's Benefit Rate Adjusted Due to Termination of Benefits to Another Beneficiary | 440 | 3 |
| Change in One Beneficiary's Rate—Wage Earner's and Spouse's Benefits Combined | 441 R | None |
| Form SSA-L562 Change in Rate Reasons | 462(A-M) | 1 |
| Waiver of Deduction Overpayment—Auxiliary Beneficiaries | 624 | 1 |
| Overpayment—30 Day Adjustment Paragraph | 651 R | None |
| Student Entitled—Family Maximum Case—No Adjustment Required | 652 | 1 |
| Late Filing of Report—Beneficiary Not Previously Notified of Good Cause and Penalty—No Child-in-Care Deduction | 656A R | 2 |
| Auxiliary Beneficiary Living With W/E Also Overpaid—Request for Refund (to be added to W/E's Notice) | 662 | 3 |
| Auxiliary Beneficiary Living With W/E Also Overpaid—Adjustment Possible (to be added to W/E's Notice) | 663 | 7 |
| Combined Check—Check for Month Subsequent to Month of Death Adjusted Against Current Benefits | 676 | 2 |
H. Terminations
| Paragraph | Fill-ins | |
|---|---|---|
| To Former Wife—Child No Longer Entitled | 16(A) | None |
| Wife Under 62 and Widow Under 60 (50 if Disabled)With Payee—Child No Longer Entitled | 52(C) | 2 |
| Child Receiving Direct Payment—Age 18—Terminated | 61(A) | 1 |
| Child Paid By Employer While Attending School | 209(A) | None |
| School Does Not Qualify as an Educational Institution | 209(B) | 1 |
| Disability Ceases—Payments Terminate | 412 | Varies |
| Title II—VR Continued Payments—Termination Paragraph | 413 | 2 |
| Title XVI—VR Continued Payments—Termination Paragraph | 414 | 2 |
| Title II—VR Cessation-Auxiliaries in Separate Households—VR Payments Terminate | 415 | 1 |
| Title II—VR Cessation—Auxiliaries in the Same Household—VR Payments Terminate | 417 | 3 |
| Spouse (B1) (B2), Age 62 When Last Child Terminated | 671 | None |
I. Appellate Process and Attorney Fees
| Paragraph | Fill-ins | |
|---|---|---|
| Court Order Provides for Payment of Attorney Fees | 145 | 2 |
| Notice to Auxiliary Living Apart that Court Order Does Not Provide for Payment of Attorney Fee | 146.2 | 4 |
| Direct Payment of Attorney's Fee at the Time Award is Made to Claimant | 147 | 1 |
| Combined Notice Where Direct Payment of Attorney Fee is Made at the Time Award is Made to Claimant | 147.1 | 1 |
| Separate Notice to Auxiliary Where Attorney Fee Has Not Yet Been Authorized | 148.2 | 1 |
| Title II Offset Cases When a Fee for Representation is Involved (Offset Adjustment Notice) | 970 | 4 |
| Authorized Check Equals Amount of Past-Due Benefits Withheld | 980 | None |
| Authorized Check is Less Than Amount of Past-Due Benefits Withheld | 980.1 | 1 |
| Authorized OHA Fee Equals Amount of Past-Due Benefits Withheld | 980.4 | 1 |
| Authorized OHA Fee is Less Than Amount of Past-Due Benefits Withheld | 980.5 | 2 |
| Authorized OHA Fee Exceeds Amount of Past-Due Benefits Withheld | 980.6 | 2 |
| Fee Waiver or Statement That No Fee Will be Charged | 981.1 | None |
| Waiver of Right to Direct Payment | 981.2 | None |
| Future Month of Entitlement Case—No Past-Due Benefits Available | 981.3 | None |
| Fee Petition Incomplete After District Office Contact | 982 | None |
| Representative is Not an Attorney | 983 | None |
| Fee Waiver (or Statement That No Fee Will Be Charged) Received After Past-Due Benefits Have Been Withheld | 985 | 2 |
| Prior Payment to Attorney—Additional Benefits Available | 986 | 4 |
| Questionable Attorney-Client Relationship | 987 | 1 |
J. Medicare
| Paragraph | Fill-ins | |
|---|---|---|
| SMIB Termination Reversal Paragraphs—Computer Generated if Effective Month of Buy-in Precedes Termination Month Shown as “MT” Factor in Item 7 of SSA-101 | 6K | None |
| Disallowance of Claim for Hospital Insurance—Not Full Retirement Age | 265 | 1 |
| Disallowance of Claim for Hospital and Medical Insurance Coverage—Not 65—Applicant Filed Under Deemed Insured Provision | 266 | 1 |
| Medical Insurance Beneficiary (“M” BIC) Potential Entitlement as Spouse of Premium Payer | 267 | 1 |
| Covered or Potentially Covered Under the Federal Employees Health Benefits Act of 1959—Deemed Insured | 272 | None |
| Applied Before Beginning of Initial Enrollment Period | 274 | None |
| Not a Resident of One of the 50 States or the District of Columbia | 278 | 1 |
| Special QC's Requirement for Entitlement to HI Under Deemed Insured Provisions—Full Retirement Age In or After 1968 | 284 | 2 |
| Chronic Renal Disease Disallowance—Opening Paragraphs | 290 | 1 |
| Disability Established—Health Insurance Coverage Date Begins More Than 2 Months After the Current Operating Month, HI/SMI Begins in Same Month | 295 | 1 |
| Medicare Termination—Revised Date of Entitlement | 297 | 1 |
| to Disability Benefits | 297 | 1 |
| Lead-in Paragraph—Medical Premiums Due | 368 | 2 |
| Suspension of Benefits or Payment Deferred Beyond Current Year—Combined Payments—A and B Beneficiaries Enrolled Under SMI (A Worked) | 703R | None |
| Deferred Payment Action—To Recover Overpayment Liable for Premiums | 704 | None |
| Deferred Payment Action—To Recover Overpayment Redeferred for Premiums Due | 705 | None |
| One-Check-Only Followed by a Suspension-Combined Check Situation (A Worked)—Both A and B Enrolled in SMI | 707 | 1 |
| One-Check—Only Followed by a Deferred Payment Action in Current Year | 708 | 1 |
| To Secondary Beneficiary-Monthly Benefit Payable Less Than $1 | 709 | 5 |
| To Secondary Beneficiary—Monthly Benefit Payable is Same as Premium | 710 | 2 |
| To Secondary Beneficiary—Monthly Benefit Payable is Less Than Premium | 711 | 6 |
| Representative Payee for HI and/or SMI Enrollee | 716 | 3 |
| Termination of Monthly Benefits and HI With SMI Entitlement Transferred to New Account | 718 | None |
| Explanation of Medicare Premiums and Deductions Under Public Law (P.L.) 97-248, Sec. 278 | 719 | None |
| Discontinuance of State Buy—In Due to Non-Payment of SSI | 728 | None |
| Continuance of State Buy-In When SSI Payments Stopped | 729 | None |
| DIB Terminates—HI/SMI Coverage Terminates—No Refunds on Remittance Due | 741 | 1 |
| DIB Terminates—HI/SMI Coverage Terminates—Premium Arrearage Exists—No DIB Overpayment or Underpayment | 742 | 4 |
| DIB Terminates From Suspense—DIB Underpayment HI/SMI Premiums for Month Following Month of Notice to be Deducted From DIB Underpayment—Beneficiary Not Billed for SMI Premiums (to be used in conjunction with paragraph No. 741) | 743 | 3 |
| DIB Terminates From Suspense—DIB Underpayment for Months—HI/SMI Premiums for Month Following Month of Notice to be Deducted From DIB Underpayment—Beneficiary Not Billed for SMI Premiums | 743(A) | 4 |
| DIB Terminates From Suspense—No DIB Overpayments or Underpayments Beneficiary Billed for SMI Premiums—Premium Arrearage Exists (to be used in conjunction with paragraph No. 741) | 744 | 4 |
| DIB Terminates From Suspense—DIB Underpayment—Beneficiary Billed for SMI Premium—Premium Arrearage Exists Which Will be Deducted From the Next Check (to be used in conjunction with paragraph No. 741) | 745 | 4 |
| DIB Terminates From Suspense—DIB Underpayment for Multiple Months—Beneficiary Billed for SMI Premiums—Premium Arrearage Exists Which Will be Deducted From the Next Check | 745(A) | 5 |
| DIB Terminates—HI Coverage Terminates—No SMI Coverage | 746 | 1 |
| SMI Refund Paragraph (to be used in conjunction with paragraph No. 741 when excess premiums will be refunded by SOBER) | 747 | None |
| Medicare Ineligibility Paragraph (to be used when beneficiary's DOST and DOCA are prior to the date of entitlement to HI/SMI. It is also to be used when a Future Cessation Date (FCD) equal to or earlier than the date of entitlement to HI/SMI is being established.) | 748 | None |
| DIB Terminates—HI/SMI Coverage Terminates—Premium Arrearage Exists Along With DIB Overpayment | 749 | 3 |
| DIB Terminates—HI/SMI Coverage Terminates—Premium Arrearage Exists for One Month Along With DIB Overpayment | 749(A) | 3 |
| DIB Terminates—HI/SMI Coverage Terminates—Premium Arrearage Exists for Prior Months Along With DIB Overpayments | 749(B) | 4 |
| DIB Terminated From Suspense—DIB Overpayment Exists—Beneficiary Billed for SMI Premiums—Premium Arrearage Exists (to be used in conjunction with paragraph No. 741) | 750 | 3 |
| DIB Terminated-Excess SMI Premiums Used to Reduce Overpayment | 751 | 4 |
| DIB Terminated From Suspense—DIB Underpayment for One Month—Excess Premiums to be Refunded by SOBER | 752 | 6 |
| DIB Terminated From Suspense—DIB Underpayment for Multiple Months—Excess Premiums to be Refunded by SOBER | 752(A) | 7 |
| HI and SMI Coverage for RD Beneficiaries (Dialysis) | 790 | None |
| Closed Period—Entitlement/Termination (Dialysis) | 791 | 3 |
| HI/SMI Termination Due to RD Cessation (Dialysis) | 792 | 2 |
| Equitable Relief—RD Termination Cases—DOTH is Earlier Than DOTS—Beneficiary Not Notified Timely (Dialysis) | 793 | 4 |
| HI and SMI Coverage for RD Beneficiaries (Transplant) | 794 | 2 |
| HI/SMI Termination Due to RD Cessation (Transplant) | 795 | 2 |
| Equitable Relief-RD Termination Cases—DOTH is Earlier Than DOTS—Beneficiary Not Notified Timely (Transplant) | 796 | 4 |
| NH—Capacity for SGA | 850 | 1 |
| NH—Impairment Not Severe—Medical Consideration Alone | 851 | None |
| NH—Impairment Not Severe—Medical Consideration Alone (Date ER Last Met) | 852 | 1 |
| NH or Disabled Child—Impairment Not Expected to Last 12 Months | 853 | None |
| NH or Disabled Child—Impairment Did Not Last 12 Months | 854 | None |
| Disabled Child—Impairment Not Severe—Medical Consideration Alone or Condition Disabling But Did Not Exist Before Age 22 (Over Age 22) | 855 | None |
| Disabled Child—Impairment Not Severe—Medical Consideration Alone or Condition Disabling But Did Not Exist Before Age 22 (Under Age 22) | 856 | None |
| Disabled Child—Capacity for SGA—Vocational Consideration (Over Age 22) | 857 | None |
| Disabled Child—Capacity for SGA—Vocational Consideration (Under Age 22) | 858 | None |
| NH—Not Disabled Before Insured Status Expired | 859 | 2 |
| NH—Not Insured at Alleged Onset Or Later | 860 | None |
| Disabled Widow(er)'s Prescribed Period Expired Before Alleged Onset | 861 | 2 |
| NH—Explanation of Disability Requirement | 862 | None |
| Disabled Widow(ers)—Explanation of the Disability Requirement and the Prescribed Period | 863 | None |
| Expiration of Widow(er)'s Prescribed Period | 864 | 2 |
| Childhood Disability—Law Paragraph—Claimant Age 22 or Over | 865 | None |
| Childhood Disability—Law Paragraph—Claimant Not Yet Age 22 | 866 | None |
| Widow(ers), Mother, Father or Surviving Divorced Spouse Entitled to Survivors Benefits—Claim Filed for Medicare Coverage—Explanation of Disability Requirement for Medicare Coverage | 867 | None |
| Widow(ers) Not Disabled—Lack of Severity | 868 | None |
| Widow(ers)—Not Disabled at Any Time Prescribed Period Requirement Met For Deemed Entitlement to Medicare Coverage | 869 | 1 |
| NH—Disabled Widow(ers) or Child—Applicant Does Not Want to Continue Development of Claim | 870 | None |
| NH—Disabled Widow(ers) or Child—Failure to Follow Prescribed Treatment | 872 | None |
| Widow(ers) Not Disabled—Impairment is Severe at Time of Adjudication But Not Expected to Last 12 Months | 874 | None |
| Widow(ers) Not Disabled—Impairment No Longer Severe At Time of Adjudication and Did Not Last 12 Months | 875 | None |
| NH—Disabled Widow(ers) or Child—Insufficient Evidence Furnished | 876 | None |
| NH—Disabled Widow(ers) or Child Fails or Refuses to Submit to Medical Examination | 877 | None |
| NH or Widow(er) Has Demonstrated Ability to Engage in SGA Despite Condition | 881 | None |
| NH Demonstrated Ability to Engage in SGA Despite Impairment Within 29 Months Before Attaining Full Retirement Age | 883 | None |
| NH—Claim Filed After Death—Not Disabled at Any Time Earnings Requirement Met | 884 | 4 |
| NH—Claim Filed After Death—Not Disabled—Lack of Severity | 885 | 3 |
| NH—Claim Filed After Death—Not Disabled—Impairment is Severe At Time of Death But Would Not Have Been Expected to Last 12 Months | 886 | 2 |
| NH—Claim Filed After Death—Not Disabled—Impairment No Longer Severe At Time of Death and Did Not Last 12 Months | 887 | 3 |
| NH—Claim Filed After Death—Insufficient Evidence | 888 | 1 |
| NH—Claim Filed After Death—Denial—Applicant Does | 889 | 2 |
| Not Want To Continue Development of Claim NH—Claim Filed After Death—Denial—Impairment Was Severe But Claimant Failed to Follow Prescribed Treatment | 890 | 4 |
| NH—Claim Filed After Death—Not Disabled At Any Time Earnings Requirement Met—Medical Consideration Alone | 891 | 4 |
| NH—Claim Filed After Death—Not Disabled—Lack of Severity—Medical Consideration Alone | 892 | 2 |
| DIB or CDB Medical Cessation | 893 | 2 |
| DIB or CDB Cessation—Work Activity (No Trial Work Period) | 894 | 2 |
| DIB or CDB Cessation—Whereabouts Unknown or Failure to Cooperate—Required Information Not Submitted | 895 | 2 |
| DIB or CDB Cessation—Whereabouts Unknown or Failure to Cooperate—Requested Medical Examination Not Taken | 896 | 2 |
| Disability Ends Prior to Beginning of Medicare Coverage | 897 | None |
| Disability Ends After Medicare Coverage Begins | 898 | None |
| CDB Reentitlement Notice | 899 | 1 |
| Medicare Coverage Termination | 901 | 1 |
| DWB Cessation—Medical Evidence Indicates Ability to Perform SGA | 902 | 2 |
| Medicare Termination—Disability Ends Prior to Medicare Coverage | 903 | None |
| Medicare Termination—Disability Ends After Medicare Coverage Begins | 904 | 1 |
| State Agency and M.D. Participation in Decision | 914 | None |
| Prior Freeze Not Affected by Current Denial | 916 | None |
| Periodic Review Scheduled | 917 | None |
| Lead-In Language for Closed Period and Later Onset Date Allowances | 918 | None |
| Disability Requirement and 7-Year Period Attachment | 919 | None |
| Disability and Earnings Requirement Attachment | 920 | None |
| Dual Entitlement—Subsequent Award—Medicare Awarded Previously and Will Continue on First Account | 940 | None |
K. Extended Period of Eligibility
| Paragraph | Fill-ins | |
|---|---|---|
| EPE Case—Cessation—9 Months of Trial Work Complete Beneficiary Performing SGA | 905 | 3 |
| EPE Case—Explanation of 15-Month Reinstatement Period | 906 | None |
| EPE Case—Impairment-Related Work Expenses Not Allowed As Claimed | 907 | None |
| EPE Case—Impairment-Related Work Expenses Insufficient to Reduce Earnings Below SGA | 908 | None |
| EPE Case—9 Months of Trial Work Complete—Medical Review—Disability Continues | 909 | None |
| EPE Case—9 Months of Trial Work Complete—Medical Review—Disability Ceases | 910 | 1 |
| EPE Case—Medicare Has Begun Prior to End of TWP | 911 | None |
| EPE Case—If 24th Month of Entitlement Has Not Been Reached Prior to End of TWP | 912 | 1 |
| Expiration of Disability Insured Status | 913 | 2 |
L. General Miscellaneous
| Paragraph | Fill-ins | |
|---|---|---|
| Change of Payee—Former Representative Payee An Individual | 35R | 1 |
| Change of Payee—Former Representative Payee an Agency or Institution | 35(A) R | 1 |
| Applicant Not Entitled to Underpayment—Not on Priority List | 50(D) | 2 |
| Applicant Not Entitled to Underpayment—Another Individual Higher in the Order of Priority Who is Eligible to Receive Underpayment | 50(E) | 3 |
| No Underpayment Exists—Request for Payment Denied | 50(F) | None |
| U.S. Federal Income Tax Withheld from Underpayment Paid to Nonresident Alien | 51 | 2 |
| Award Amended to Exclude Disability Period | 70 | None |
| Exclusion of Disability Period Does Not Increase Benefit | 71 | None |
| Primary Benefits Based on Transitionally Insured Status | 73 | 1 |
| Address Paragraph for ALJ, ODO, PSC, OHA | 160 | 1 |
| Fee Petition Paragraph for Court Cases | 161 | None |
| Applicant Not Entitled to Monthly Benefits—Worker Not Fully Insured | 201 | 2 |
| To Husband or Widower—W/E or S/E Person Not Fully and Currently Insured | 202 | 2 |
| Spouse Not Yet 62 and No Child in Care Age 16 or Under or Disabled | 205(B)R | None |
| Child 18 or Over Not Disabled or a Full-Time Student | 209 | 1 |
| Child Paid by Employer While Attending School | 209(A) | None |
| School Does Not Qualify As an Educational Institution | 209(B) | 1 |
| Widow/Widower Under 60—No Child “In-Care” —Child Entitled to Benefits | 212 | 1 |
| If the Widow/Widower May Become Entitled to Benefits at Age 60, Add the Following | 212(A) | 1 |
| Surviving Divorced Spouse Not Entitled, Child Requirement Not Met | 213(A) | 1 |
| Disallowance for More Than One Reason but Insufficient Proof in File to Make Decision | 240 | 1 |
| Insured Individual Died After Deportation | 244 | None |
| Wife, Child, or Husband Disallowed Because W/E Not Entitled to RIB or DIB | 245 | None |
| Denial of Requests for Withdrawal of Claim—Requested Consent Statements Absent | 251 | None |
| Denial of Request for Withdrawal—Refund Not Made | 252 | 1 |
| Withdrawal Approved, New Award Made—Notice to Person Whose Entitlement is Nullified | 255 | 4 |
| Withdrawal Approved—Notice to Wife, Husband or Child Whose Entitlement is Nullified | 256 | 4 |
| Insert Paragraph for Form SSA-L250 (SSA-L850)—Withdrawal Approved After Award | 257 | None |
| Insert Paragraph for Form SSA-L250 (SSA-L850)—Withdrawal Approved Before Adjudication | 258 | None |
| Wife or Widow—Under 72—W/E Transitionally Insured | 261 | 2 |
| Widow Age 72 or Over Disallowed—No Transitional Insured Status—W/E Attained 65 or Died Before 1957 | 263 | 3 |
| Request for Change of Address—Claimant Entitled to Hospital Insurance Benefits But Not Monthly Benefits | 264 | None |
| Not a Resident of U.S.—Deemed Insured | 270 | None |
| Not a U.S. Citizen and Does Not Meet Alien Residency Requirement—Deemed Insured | 271 | None |
| Claim Disallowed For Nonmedical Reasons—Disability Determination Unnecessary | 288 | None |
| Lead-in Paragraph | 306 | 2 |
| Reconsideration Paragraph | 307 | 2 |
| Hearing Paragraph | 308 | 1 |
| Right to File Subsequent Application | 309 | 1 |
| DIB—Not Qualified Before Full Retirement Age—Substantial Gainful Work313(A) | None | |
| Disability Denial—General Closeout Paragraph | 314 | None |
| Description of Earnings Requirement—Special Insured Status Requirements for Subsequent Period of DIB | 320.9 | None |
| Allowance—Subsequent Period of DIB, Special Insured Status—Benefits Payable 5/83, First Possible Month of Entitlement Earlier | 321 | 1 |
| Applicant Mentions Another Disability Program | 351 | None |
| Reexamination Scheduled—Beneficiary Hospitalized | 354 | 1 |
| Statutory Blindness—DIB Allowance Under 1972 Amendments—First Month of Entitlement Restricted to 01/73 | 358 | 2 |
| Initial Notice—Reference to Follow-up Notice if Title II Underpayment or Overpayment Involved | 365 | None |
| Lead-in Paragraph—Underpayment of Title II Benefits Involved | 366 | 2 |
| Lead-in Paragraph—Overpayment of Title II Benefits Involved | 367 | 2 |
| DIB—Rate Increase—Two Rates Payable | 372 | None |
| DIB—Rate Increase—Change in Disability Period | 374 | None |
| Claimant Insured for RIB—No RIB Claim Filed | 378 | None |
| Information Concerning Hospital and Medical Insurance—Claimant Age 63-64 3 /4 | 379 | None |
| DIB and DWB Applications Filed | 380R | None |
| Freeze or DIB Continuance (After Full Retirement Age) | 388 | None |
| DWB Cessation—Medical Improvement | 396 | 3 |
| DIB Cessation—Overpayment Involved | 397 | 3 |
| DIB Cessation—Overpayment Involved—SMI Premiums Included in Overpayment | 397(A) | 4 |
| DIB Cessation—Underpayment Involved for One Month | 398 | 3 |
| DIB Cessation—Underpayment Involved for Multiple Months398(A) | 4 | |
| Title II “Lead-in” Paragraph | 399 | None |
| Request for Refund | 399(A) | 1 |
| Disability Ceases—Payments Continue | 408 | 2 |
| Personalized Notice Lead-In | 409 | None |
| Title II VR Cessation-Auxiliaries in Separate Households—Payments Continue | 410 | 1 |
| Title II-VR Cessation—Auxiliaries in Same Household—Payments Continue | 411 | 1 |
| Combined Check—Primary or Auxiliary Beneficiary Dies—Check for Month Subsequent to Month of Death Outstanding | 679R | None |
| SSA-1560-U4 Return Address Paragraph SEPSC | 731 | None |
| Reference to Title XVI Claim—Dual Entitlement Case (Title XVI Disclaimer Paragraphs) | 842 | None |
| Multiple Claims—Benefits Being Paid on One—Current Claim Being Denied | 900 | None |
| Government Pension Total Offset | 1000 | None |
| Government Pension Partial Offset | 1001 | None |
M. Continuing Disability Review Cessations
| Paragraph | Fill-ins | |
|---|---|---|
| Lead In - Medical Improvement Cessation - Title II | 4000 | None |
| Lead In - Group I Exception - Title II | 4001 | None |
| Lead In - Medicare Only - Current Coverage - Medical Improvement | 4002 | None |
| Lead In - Medicare Only - Current Coverage - Group I Exception | 4003 | None |
| Lead In - Medicare Only - Future Coverage - Medical Improvement | 4004 | None |
| Lead In - Medicare Only - Future Coverage - Group I Exception | 4005 | None |
| Lead In - Reopening To Cessation - Medical Improvement - Title II | 4006 | None |
| Lead In - Reopening To Cessation - Group I Exception - Title II | 4007 | None |
| Lead In - Reopening To Closed Period - Medical Improvement - Title II | 4008 | None |
| Lead In - Reopening To Closed Period - Group I Exception - Title II | 4009 | None |
| Lead In - Medicare Only - Reopening To Cessation - Current Coverage - Medical Improvement | 4010 | None |
| Lead In - Medicare Only - Reopening To Cessation - Current Coverage - Group I Exception | 4011 | None |
| Lead In - Medicare Only - Reopening To Cessation - Future Coverage - Medical Improvement | 4012 | None |
| Lead In - Medicare Only - Reopening To Cessation - Future Coverage - Group I Exception | 4013 | None |
| Lead In - Auxiliary Notice | 4014 | 3 |
| Lead In - Group II Exception - Title II | 4022 | None |
| Lead In - Later Cessation - Medical Improvement - Title II | 4038 | 2 |
| Lead In - Basis Change Only | 4040 | None |
| Referral To Personalized Attachment | 4041 | None |
| Benefits/Payments End | 4043 | 2 |
| Benefits End - Auxiliary | 4044 | 3 |
| Medicare Ends | 4048 | 1 |
| Medicare Ends - Medicare Only | 4049 | 2 |
| No Future Medicare Coverage | 4051 | 2 |
| Vocational Rehabilitation - Title II | 4052 | None |
| DDS Decision | 4054 | None |
| Right to Reconsideration | 4056 | None |
| Right To Reconsideration - Disability Cessation - Section 301 Case | 4057 | None |
| Benefit Continuation - Medicare Involved - Primary Beneficiary - Title II | 4059 | None |
| Benefit Continuation - Auxiliary | 4060 | 1 |
| Benefit Continuation - Medicare Involved - Later Cessation or Basis Change Only | 4063 | None |
| Benefit Continuation - Later Cessation or Basis Change Only - Auxiliary | 4064 | 1 |
| Disability Hearing Information | 4066 | None |
| If You Need Help With Your Appeal | 4069 | None |
| Things To Remember - Title II | 4070 | None |
| Things To Remember - Medicare - Current Coverage | 4071 | None |
| Things To Remember - Medicare - Future Coverage | 4072 | None |
| DO Referral | 4078 | None |
| DIB, DI or CDB Medical Cessation – Title II/XVI” | 4080 | 1 |
| Disability Cessation - Clear Cut - Title II | 4081 | 1 |
| DIB, DWB or CDB Cessation - Whereabouts Unknown or Failure to Cooperate - Required Information Not Submitted - Title II | 4082 | 1 |
| DIB, DWB, CDB Cessation - Whereabouts Unknown or Failure to Cooperate - Requested Medical Examination Not Taken - Title II | 4083 | 1 |
| Medical Cessation - Advances in Medical Therapy or Technology - Title II/ Title XVI | 4084 | 1 |
| Medical Cessation - Advances in Vocational Therapy or Technology - Title II /Title XVI | 4085 | 1 |
| Medical Cessation - New or Improved Diagnostic or | 4086 | 1 |
| Evaluative Techniques - Title II/Title XVICessation - Prior Determination in Error - Title II/Title XVI | 4087 | 1 |
| Cessation - Fraud - Title II/Title XVI | 4088 | 1 |
| Failure to Follow Prescribed Treatment - Title II/Title XVI | 4095 | 1 |
| DWB Medical Cessation - Title II | 4096 | 1 |
| Benefit Continuation Rights - Medicare Not Involved | 4097 | None |
| Appeal Rights - Face-to-Face Hearing - Reopening to a Later Onset | 4098 | None |
| Appeals Rights - ALJ Hearing - Title II | 4104 | None |
| Benefits End - Later Cessation - Title II | 4115 | 2 |
| Lead In - Reopening To Later Cessation - No Medical Improvement - Title II | 4116 | 2 |
| Lead In - Reopening To Cessation - Group II Exception - Title II | 4127 | None |
| Right To Reconsideration (Foreign Claim) | 4131 | None |
| Right To Reconsideration - Auxiliary (Foreign Claim) | 4132 | None |
| Right To Reconsideration - Award Notice - Revision To Later Onset (Foreign Claim) | 4133 | None |
| General Closing Paragraph (Foreign Claim) | 4134 | 1 |
| Disability Hearing Information (Foreign Claim) | 4135 | None |
| Auxiliary Notice - Lead In - Allowance To Denial | 4158 | 2 |
| Lead In - Allowance to Denial - Title II | 4159 | None |
| Right To Reconsideration - Award Notice | 4160 | None |
| Lead In - Affirmation of a Denial | 4170 | None |
| Lead In - Affirmation of a Later Onset | 4171 | 1 |
| Lead In - Affirmation of a Closed Period | 4172 | 2 |
| Appeal of the Earlier Decision | 4173 | None |
| DDS Decision - Foreign Version | 4175 | None |
| Appeals Rights - ALJ Hearing Formal Remands | 4176 | None |
| How An ALJ Hearing Works | 4177 | None |
| How An ALJ Hearing Works - Foreign Version | 4178 | None |
| DO Referral - Foreign Version | 4179 | None |
| Notice Enclosures - Cessation - Title II | 4180 | None |
| Notice Enclosures - Cessation - Title II | 4181 | None |
| Notice Enclosures - Basis Change Only | 4186 | None |
| Notice Enclosures - Basis Change Only | 4187 | None |