NL 00725.345:
“PAY” UTIs – Payment
Effective Dates: 12/21/2017 - Present- Effective Dates: 06/12/2018 - Present
TN 22 (12-17)- TN 25 (06-18)
- NL 00725.345 “PAY” UTIs – Payment
- PAYC01 Caption
- What We Will Pay And When
- PAYC02 Caption
- (1) Payment of $ (2)
- Fill-ins:
- (1) “Your”/SN possessive
- (2) Amount of payment
- PAYC03 Caption
- (1) Regular Monthly Payment
- Fill-in:
- (1) “Your”/SN possessive
- PAYC04 Caption
- (1) Payment of $ (2)
- Fill-ins:
- (1) “Your”/SN possessive
- (2) Amount of first payment
- PAYC12 Caption
- Why We Cannot Pay Current Benefits
- PAYC15 Caption
- Why We Cannot Pay Past Benefits
- PAYR01 Partial Award
We used (1) (2) to decide how much to pay (3) . We are still working on (4) claim. When we make a final decision about the (5) , we will figure the amount of (6) payments. We will send (7) another letter to let (8) know if there will be any change in (9) payments.- We used (1) (2) to decide how much to pay (3) . We are still working on (4) claim. When we make a final decision about the (5) , we will figure the amount of (6) payments. We will send (7) another letter to let (8) know if there will be any change in (9) payments.
- Fill-ins:
- (1) “your”/Beneficiary's FN possessive
- (2) dictated text *
- (3) “you”/“her”/“him”
- (4) “your”/“her”/“his”
- (5) dictated text *
- (6) “your”/“her”/“his”
- (7) “you”/“her”/“him”
- (8) “you”/“her”/“him”
- (9) “your”/“her”/“his”
- (*) indicates that the fill-in is manual
- PAY002 PMA or CMA Different From Ongoing Amount
You will receive $ (1) around (2) .- You will receive $ (1) around (2) .
- Fill-ins:
- (1) Amount of first payment
- (2) Month, day and year of expected receipt
- PAY003 Payment Months (Concluding Sentence for PAY002)
This is the (1) money (2) (3) due for (4) (5) (6) .- This is the (1) money (2) (3) due for (4) (5) (6) .
- Fill-ins:
- (1) null
- (2) “you”/SN/FN/First Name
- (3) “are”/“is”
- (4) month and year
- (5) “and”/“through”/null
- (6) month and year/null
- PAY004 Current or Deferred Benefits Due
You will receive $ (1) for (2) around (3) .- You will receive $ (1) for (2) around (3) .
- Fill-ins:
- (1) Payment amount
- (2) Month and year payment is due
- (3) Month, day and year of expected receipt
- PAY006 Medical Insurance Premium Deduction
- The above amounts may change because of medical insurance premium deductions.
- PAY009 Ongoing Benefit Amount
(1) After that you will receive $ (2) (3) (4) (5) .- (1) After that you will receive $ (2) (3) (4) (5) .
- Fill-ins:
(1) null/”You will receive”- (1) null/“You will receive”
- [1a] for [1b].
- [1a] Money fill-in
- [1b] Date fill-in the format “September 1995”
- (2) Money fill-in
- (3) “on or about the”/“for”/“through”
(4) “third”/ “second Wednesday”/ “third Wednesday”/ “fourth Wednesday”/Date in the format “July 1994”- (4) “third”/“second Wednesday”/“third Wednesday”/“fourth Wednesday”/Date in the format “July 1994”
- (5) “of each month”/null
- PAY012 Payment Through Direct Deposit
- (1) and any future payments will go to the financial institution you selected. Please let us know if you change your mailing address, so we can send you letters directly.
- Fill-in:
- (1) “These”/“This”
- PAY013 Monthly Credited Amount Less than One Dollar
- (1) monthly benefits are less than a dollar. So, we will not pay you a check each month. We will hold the monthly benefits (2) due and pay you this money at the end of the year.
- Fill-ins:
- (1) “Your”/SN possessive/FN possessive/First Name possessive
- (2) “you are”/“she is”/“he is”
- PAY018 Summary Sheet Included
Later in this letter, we will show you how we figured (1) (2) .- Later in this letter, we will show you how we figured (1) (2) .
- Fill-ins:
- (1) null
- (2) “this amount”/“these amounts”
- PAY019 Summary Sheet - Introduction
- Here is how we figured (1) (2) (3) :
- Fill-ins:
- (1) “your”/FN possessive
- (2) “first payment”
- (3) null
- PAY020 Summary Sheet – Benefits Due
- Benefits due for (1) . . . . . . . . . . . . . . (2)
- Fill-ins:
- (1) month and year
- (2) null/“,”
- PAY022 Summary Sheet – Subtraction Explanation
- (1) we subtracted because (2)
- Fill-ins;
- (1) “Amount”/“Amounts”
- (2) “of:”/“of”
- PAY023 Summary Sheet - Introduction
- Here is how we figured (1) (2) effective (3) :
- Fill-ins:
- (1) FN possessive/“your”
- (2) “regular monthly payment”
- (3) Month and year
- PAY024 Summary Sheet – Monthly Benefit Amount
- (1) entitled to a monthly benefit of (2) . . . . . . . (3)
- Fill-ins:
(1) “you are”/“she is”/“he is”- (1) “You are”/“She is”/“He is”
- (2) null/variable length ellipsis
- (3) MBA amount
- PAY025 Summary Sheet – Monthly Payment Amount
- This equals the amount of (1) (2) (3) (4)
- Fill-ins:
- (1) SN possessive/“your”
- (2) “first payment”
- (3) variable length ellipsis
- (4) Money amount
- PAY026 Summary Sheet - Introduction
- Here is how we figured (1) (2) benefits:
- Fill-ins:
- (1) FN possessive/“your”
- (2) “current”/“past”
- PAYC27 Caption
- How (1) Benefits Can Be Paid
- Fill-in:
(1) Beneficiary's name (possessive)/ Your- (1) Beneficiary's name (possessive)/Your
- PAY027 Summary Sheet – Subtraction Explanation
(1) we must subtract because (2) .- (1) we must subtract because (2) .
- Fill-ins:
- (1) “Amount”/“Amounts”
- (2) “of”/“of:”
- PAY028 Summary Sheet – Conditional Award Total
- This equals . . . . . . . . . . . . . . .$00.00
- PAY030 Combined Check
(1) benefit is $ (2) on (3) earnings record and $ (4) as a (5) .- (1) benefit is $ (2) on (3) earnings record and $ (4) as a (5) .
- Fill-ins:
(1) “your”/ “her”/ “his”- (1) “Your”/“Her”/“His”
- (2) Money fill-in
(3) “your”/ “her”/ “his”- (3) “your”/“her”/“his”
- (4) Money fill-in
- (5) Type of benefit
- PAY032 Auxiliary/Survivor Awarded after Primary
(1) benefit is $ (2) as a (3) . This is in addition to the benefit of $ (4) on (5) own earnings record.- (1) benefit is $ (2) as a (3) . This is in addition to the benefit of $ (4) on (5) own earnings record.
- Fill-ins:
(1) “your”/ “her”/ “his”- (1) “Your”/“Her”/“His”
- (2) Money fill-in
- (3) Type of benefit
- (4) Money fill-in
(5) “your”/ “her”/ “his”- (5) “your”/“her”/“his”
- PAY033 Technical Entitlement – PMA Only Due in Addition to Regular Payment
(1) will also receive a payment of $ (2) for (3) . This is the only money (4) due on claim number (5) .- (1) will also receive a payment of $ (2) for (3) . This is the only money (4) due on (5) record.
- Fill-ins:
(1) “you”/ “she”/ “he”- (1) “He”/“She”/“You”
- (2) Money fill-in
- (3) Date fill-in
(4) “you are”/ “she is”/ “he is”- (4) “he is”/“she is”/“you are”
(5) DE other account SSN- (5) “his”/“her”/“your”
- PAY041 Summary Sheet – SMI Arrearage
Additional amount we subtracted for medical insurance premium due one month in advance (1) .- Additional amount we subtracted for medical insurance premium due one month in advance (1) .
- Fill-in:
- (1) Premium amount
- PAY042 Summary Sheet – Benefits Due
- Benefits due for (1) . . . . (2) . . . . (3)
- Fill-ins:
- (1) Month and year
- (2) null or variable length ellipsis
- (3) Amount
- PAY043 Payment Months (Concluding Sentence for PAY002, Two Periods of Payment)
This is the (1) money (2) due for (3) (4) (5) and (6) (7) (8) .- This is the (1) money (2) due for (3) (4) (5) and (6) (7) (8) .
- Fill-ins:
- (1) null
(2) “you are”/ “she is”/ “he is”- (2) “you are”/“she is”/“he is”
- (3) Month and year
- (4) “and”/“through”/null
- (5) Month and year/null
- (6) Month and year
- (7) “and”/“through”/null
- (8) Month and year/null
- PAY044 Payment Months (Concluding Sentence for PAY002, Three Periods of Payment)
This is the (1) money (2) due for (3) (4) (5) , (6) (7) (8) and (9) (10) (11) .- This is the (1) money (2) due for (3) (4) (5) , (6) (7) (8) and (9) (10) (11) .
- Fill-ins:
- (1) null
- (2) “you are”/“she is”/“he is”
- (3) Month and year
- (4) “and”/“through”/null
- (5) Month and year/null
- (6) Month and year
- (7) “and”/“through”/null
- (8) Month and year/null
- (9) Month and year
- (10) “and”/“through”/null
- (11) Month and year/null
- PAY045 Payment Months (Concluding Sentence for PAY002, Four Periods of Payment)
This is the (1) money (2) due for (3) (4) (5) , (6) (7) (8) , (9) (10) (11) and (12) (13) (14) .- This is the (1) money (2) due for (3) (4) (5) , (6) (7) (8) , (9) (10) (11) and (12) (13) (14) .
- Fill-ins:
- (1) null
- (2) “you are”/“she is”/“he is”
- (3) Month and year
- (4) “and”/“through”/null
- (5) Month and year/null
- (6) Month and year
- (7) “and”/“through”/null
- (8) Month and year/null
- (9) Month and year
- (10) “and”/“through”/null
- (11) Month and year/null
- (12) Month and year
- (13) “and”/“through”/null
- (14) Month and year/null
- PAY046 Summary Sheet – Work Deductions (Use with PAY022)
- (1) work (2) (3)
- Fill-ins:
- (1) NH FN possessive/“Your”
- (2) null/variable length ellipsis
- (3) Amount
- PAY047 Summary Sheet – Maritime Tax Subtraction (Use with PAY022)
- unpaid Social Security taxes due for (1) maritime taxes. . . . (2)
- Fill-ins:
- (1) FN possessive/“your”
- (2) Amount
- PAY048 Summary Sheet – SMI Premium Subtraction (Use with PAY022)
- premiums for medical insurance . . . . . . . . . . (1)
- Fill-in:
- (1) Amount of premiums
- PAY049 Summary Sheet - Subtotal
- This equals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (1)
- Fill-in:
- (1) Amount
- PAY050 Summary Sheet - Rounding
- rounding [we must round down to a whole dollar] . . . . . (1)
- Fill-in:
- (1) Rounding amount
- PAY051 Summary Sheet – Attorney Fee Withholding (Use with PAY022)
- money to pay (1) lawyer . . . . . . . . . . (2) . . . . . . . . (3)
- Fill-ins:
- (1) FN possessive/“your”
- (2) Variable length ellipsis/null
- (3) Attorney fee withholding amount
- PAY052 Summary Sheet – Alien Tax Withholding (Use with PAY022)
- U.S. Federal taxes due on (1) Social Security (2) (3)
- Fill-in:
- (1) FN possessive/“your”
- (2) null/variable length ellipsis
- (3) Amount of tax withheld
- PAY053 Summary Sheet – Total Subtractions (Use with PAY022)
- Total subtractions . . . . . . . . . . . . . . . . . . (1)
- Fill-in:
- (1) Amount
- PAY054 Summary Sheet – Alien Non-payment (Use with PAY022)
- (1) residence outside of the U.S . . . . . . . . . (2)
- Fill-ins:
- (1) FN possessive/“your”
- (2) Amount
- PAY055 Summary Sheet – Prisoner Suspension (Use with PAY027)
- (1) conviction of a felony . . . . . . . . . . . . (2)
- Fill-ins:
- (1) FN possessive/“your”
- (2) Amount withheld
- PAY056 Summary Sheet – Work Deduction (Use with PAY027)
- (1) work and earnings over the limit . . . . . . . (2)
- Fill-ins:
- (1) FN possessive/“your”
- (2) Amount deducted
- PAY057 Summary Sheet – Medical Insurance (Use with PAY027)
- premiums for medical insurance . . . . . . . . . . (1)
- Fill-in:
- (1) Premium amount withheld
- PAY058 Summary Sheet (Use with PAY020)
- (1) (2) (3)
- Fill-ins:
- (1) “and”/“through”
- (2) Month and year
- (3) “,”/null
- PAY059 Summary Sheet (Use with PAY020)
- including any cost of living increase (1) (2)
- Fill-ins:
- (1) “and”/null
- (2) “,”/null
- PAY060 Summary Sheet (Use with PAY020)
- considering work and earnings through (1)
- Fill-in:
- (1) Year
- PAY061 Summary Sheet (Use with PAY042)
- (1) (2) (3) (4)
- Fill-ins:
- (1) “and”/“through”
- (2) Month and year
- (3) null/variable length ellipsis
- (4) Amount/null
- PAY062 Summary Sheet (Use with PAY042)
- with premiums for medical insurance deducted $ (1)
- Fill-in:
- (1) Amount
- PAY063 Summary Sheet
- less monthly rounding of benefits $ (1)
- Fill-in:
- (1) Amount
- PAY064 Summary Sheet
- premiums for medical insurance through (1) (2) (3)
- Fill-ins:
- (1) Month and year (COM)
- (2) null/variable length ellipsis
- (3) Amount
- PAY065 Summary Sheet
- additional premium due one month in advance . . . . $ (1)
- Fill-in:
- (1) Amount
- PAY066 Summary Sheet
- government pension offset . . . . . . . . . . . . . $ (1)
- Fill-in:
- (1) Amount
- PAY067 Payment Prior to Completion of Claim/PMA Exists
- We will subtract $ (1) from your next check. This is the amount we paid you before we finished work on (2) claim.
- Fill-ins:
- (1) CPA in format $$,$$$.¢¢
- (2) “your”/FN (Possessive)
- PAY068 Payment Prior to Completion of Claim/Equal to PMA
When we figured how much to pay you through (1) , we subtracted the money which we already paid you while we finished work on (2) claim.- When we figured how much to pay you through (1) , we subtracted the money which we already paid you while we finished work on (2) claim.
- Fill-ins:
- (1) If LAF equals C: CMA minus one month in format January 1993. If LAF does not equal C: find first EFD with equal RFD to current LAF and is greater than DOEC. This fill-in is EFD minus one month in format January 1993.
- (2) “your”/FN (Possessive)
- PAY069 Summary Sheet
- amount paid before work was finished on claim . . . . . . $ (1)
- Fill-in:
- (1) CPA in format $$,$$$.¢¢
- PAY072 Regular Monthly Payment When DAA/Installment Present
This check includes (1) regular monthly payment of (2) for (3) .- This check includes (1) regular monthly payment of (2) for (3) .
- Fill-ins:
- (1) “your”/“her”/“his”
- (2) Money amount in format $$$.¢¢
- (3) Month/year
- PAY073 DAA Past Due Benefits and Installment
- (1) still due back payments of $ (2) for past months. (3) will receive this money over a period of months. We will send (4) $ (5) more each month with (6) regular payment until all of the extra money is paid.
- Fill-ins:
(1) “you are”/“she is”/“he is”- (1) “You are”/“She is”/“He is”
- (2) Amount of past due benefit payable
- (3) “you”/“she”/“he”
- (4) “you”/“her”/“him”
- (5) Amount of installment payment
- (6) “your”/“her”/“his”
- PAY074 Voluntary Tax Amount Withheld
- voluntary withholding for Federal taxes.....................$ (1)
- Fill-in:
- (1) Amount withheld for voluntary Federal tax withholding
- PAY088 Payment Cycling
(1) next payment of $ (2) , which is for (3) , will be received on or about the (4) of (5) .- (1) next payment of $ (2) , which is for (3) , will be received on or about the (4) of (5) .
- Fill-ins:
- (1) “Your”/beneficiary's FN possessive
- (2) MBP in the format “$$$$$.¢¢”
- (3) COM in the format “June 1998”
- (4) third/second Wednesday/third Wednesday/fourth Wednesday
- (5) COM + 1, in the format “June 1998”
- PAY090 Summary Sheet (DE) Amount of Benefit on Other SSN
- (1) also entitled to a monthly benefit of......... (2) ......... (3)
- Fill-ins:
(1) “you are”/“she is”/ “he is”- (1) “You are”/“She is”/ “He is”
- (2) Variable length ellipsis
- (3) Money Fill-in
- PAY161 LAF is C but the CMA is $0.00
No Payment is due at this time because of adjustments made to (1) benefits.- No payment is due at this time because of adjustments made to (1) benefits.
- Fill-in:
- (1) “her”/“his”/“your”
x
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