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DI 26010: Completion of Form SSA-831-U5 in Blindness Cases

Effective Dates: 10/19/2015 - Present

TN 2 (10-08)

A. Procedure for Title II

1. Completing Item 18

Complete Item 18 in a Title II wage earner’s case only when statutory blindness is established.

However, do not complete this item:

when the established onset date of disability entered in Item 15A is earlier than the onset of statutory blindness. (For the required entry in Item 27 for these cases, see DI 26010.055); or
when “FZ” (freeze) is marked in Item 7 (Type Claim (Title II)) and the individual has limited the application to claim a “freeze only.”

2. Establishing a Disability Freeze

The wage earner’s earnings record is “frozen” at the point the “disability freeze” is established (that is, the date the medical evidence shows, or where reasonable medical inferences can be made, that the wage earner’s visual impairment first meets the definition of statutory blindness).

If the wage earner ceases SGA and is eligible for cash benefits, the “frozen” earnings record is used to compute disability benefits, meaning that earnings after the date the freeze is established are not used in the computation.

For a discussion of the establishment of onset for entitlement to a disability “freeze-only”, see DI 26005.001A., Title II-Policy – Onset.

A Title II wage earner who engages in substantial gainful activity (SGA) despite statutory blindness is entitled to a period of “disability freeze” even though he or she is not entitled to cash disability benefits (i.e., disability insurance benefits (DIB)).

For an exception when the individual has attained age 55, see DI 26005.001E.

See Details:

DI 26001.001, Definition of Blindness
DI 26005.001C.3.a., first bullet, Title II – SGA Levels – How to Use the SGA Dollar Guidelines – DIB Claimants and Beneficiaries (Age 55 or Older and Under Age 55)
DI 26005.001E., Title II – Policy - Work Comparability Provisions For Blind DIB, CDB, and DWB Individuals - Age 55 and Older

3. Completing Block A (Not Disab. for Cash Bene. Purp.)

Check Block A when the statutorily blind claimant has engaged in, and continues to engage in, SGA at the time of adjudication.

Also check this block when the statutorily blind claimant:

has attained age 55; and
has engaged in, and continues to engage in, comparable SGA during the 12 months before the month of filing the application. (See Title II – Work Comparability Provisions for Blind DIB, CDB, and DWB Individuals—Age 55 and Older, DI 26005.001E.).

NOTE: This includes cases where the claimant may have ceased comparable SGA for short periods and then returned to comparable SGA (for example, 1 to 2 months in the 12-month period). It is not necessary to consider whether the statutorily blind claimant engaged in comparable SGA for the months before the month of attainment of age 55 or before the first full month the claimant’s impairment meets the statutory definition of blindness, whichever is later.

4. Completing Block B (Disab. for Cash Benefit Purp. Beg.)

a. When the claimant is under age 55

Check Block B when the statutorily blind claimant has not attained age 55 and has been continuously unable to engage in any SGA, and enter the earliest date of inability to engage in SGA.

If the claimant was unable to engage in SGA for a continuous period of at least 12 months, but regained the ability to engage in SGA no more than 14 months before the month of filing the application, take the following action:

Check block B., and enter “see remarks.”
In Item 34, “Remarks,” enter “Disab. for Cash Bene. Purp. from” followed by the date of inability to engage in SGA and the date ability to engage in SGA was regained.

EXAMPLE: “Disab. for cash bene. purp. from 10/05/73 - 03/17/75.”

b. When the claimant is age 55 or older

Check block B when the statutorily blind claimant has attained age 55 and:

Did not engage in any (comparable or non-comparable) SGA after the date shown in Item 15A. (Enter the same date shown in Item 15A);
Engaged in comparable SGA after the date shown in Item 15A but subsequently stopped working entirely. (Enter the date comparable SGA ceased);
Engaged in comparable SGA after the date shown in Item 15A but subsequently changed to non-comparable SGA. (Enter the date comparable SGA ceased.); or
Continued to engage in non-comparable SGA after the date shown in Item 15A. (Enter the first day of the latest of:
1. the month of attainment of age 55,
2. the first month of the 17-month period before the month of filing the application, or
3. the first full month in which the claimant met the statutory definition of blindness);

If the statutorily blind claimant is age 55 or over and was unable to engage in comparable SGA for a period of at least 5 full calendar months but regained ability to engage in comparable SGA no more than 14 months before the month of filing the application, complete Block B as described in the bullets in this section at DI 26010.025A.4.a.

B. Procedure for Title XVI

Do not use Block A.

1. Completing Block B

If the claimant is found to be statutorily blind, check block B and enter one of the following:

the date of filing (or protective filing date);
the exact onset, if after the month of filing (or protective filing month, if any); or
the exact date of medical onset, if the medical evidence indicates an onset date earlier than the month of filing.

REMINDER: The previous instructions do not apply in non-citizen cases.

2. Blindness is established after onset of disability

If the initial determination finds the claimant to be disabled before or in the month of filing and statutorily blind after the month of filing, complete Item 15 using the regular disability (non-statutory blindness) onset date.

In Item 18, check block B, and enter the onset date of statutory blindness. Then, add a remark in Item 34, "FO revised systems input required -- disabled before or in the month of filing and became statutorily blind on (date) (MM/DD/YYYY)."

EXAMPLE: Mike Smith applied for disability and was allowed with a protective filing date of November 1, 2007. On December 17, 2007, Mike is involved in an accident and traumatically and permanently loses all vision. In this case, complete Item 15A using an onset date of 11/01/2007.

NOTE: Only use the first of the month if the protective filing date actually is the first of the month. Complete Item 18B using an onset date of 12/17/2007 for statutory blindness.

Add the remark in Item 34, "FO revised systems input required -- disabled before or in the month of filing and became statutorily blind on 12/17/2007."

3. Establishing a closed period of blindness

In a closed period case, check block B in Item 18 and show “Blind from (date) (MM/DD/YY) to (date) (MM/DD/YY).” If the FO or DDS had entered a date in Item 15 for presumptive disability, delete it.

4. Establishing blind onset for a non-citizen

If a non-citizen claimant is statutorily blind, check block B and enter the following date:

the precise onset date when the onset is established after entry into the U.S., or
Any date prior to the entry date when the onset is established before entry into the U.S. and the medical evidence does not pinpoint a precise date.