BASIC (03-86)

Where the instructions require the checking of certain blocks on the forms, comply with these requests by entering an “X” in each designated block.

A. Item 1A - social security number

Enter the social security number (SSN) of the primary beneficiary. In CDB or DWB cases, show wage earner's SSN. To the right of the SSN, enter the beneficiary identification code (BIC) shown under the BIC caption on the latest award document in the claims folder for the disabled beneficiary; e.g., “A” for disabled wage earner.

NOTE: If disabled wage earner's BIC is shown as “HA,” enter only “A” on SSA-833-U5. Also, enter any numerical suffix following a designated BIC; e.g., C1 (CDB), enter both “C” and “1.”

B. Item 1B - type of claim

C. Item 1C - other entitlement

Check as appropriate: Check the “title XVI” block if applicable. Also check the title II block if there is other title II involvement (e.g., HA-CDB, HA-DWB, etc.) and enter the SSN, upon which other entitlement is based in item 24 “Remarks” ; e.g., DWB SSN 123-00-6789.

D. Items 2 and 3 - name of payee or blind individual and address

The following information should be taken from the latest determination in file (right or left side), unless more recent information is known.

1. Block A - enter representative payee's name, if any, including the term “for,” “on behalf of,” or “guardian of.”

   NOTE: If there is a representative payee, see instructions for completion of item 29 of these instructions.

2. Block B - enter the name of the blind individual. Print the first three letters of the surname in capital letters in the block (e.g., JOHnson). If the individual named is a CDB or DWB, enter the wage earner's name in item 3 of the SSA-833-U5.

3. Block C - enter the latest mailing address for the blind individual, or, if applicable, the representative payee. The address should always include the zip code. Do not show the bank address if direct deposit is involved. In any case where the beneficiary filed on his or her own behalf and is deceased, line out the address entry and enter “beneficiary deceased.”

   NOTE: If the most current address is different from the one shown in the folder, promptly request an address change.

E. Item 4 - date of birth

Show a 6-digit figure (e.g., 01/03/59).

F. Item 5 - date disability began

Insert the date from item 15A of the latest approved SSA-831-U5 in file.

G. Item 6 - DO/BO address

Enter a complete DO/BO address and zip code.

H. Item 7 - DO/BO and DDS code

Show DO/BO code only.

I. Item 8 - adjudicative level

Check the appropriate block.

J. Item 9 - determination findings - Blocks 9A-9J

Always check the disability block.

1. Block A - Check if appropriate.

2. Block B - If disability ceased, check this block and enter the month and year of cessation. If cessation is due to failure to cooperate, the cessation date is the month in which the first written request was made to the beneficiary and it was clearly indicated that unless cooperation occurred, benefits might be terminated.

3. Block C - If applicable, check this block to indicate benefit termination. If it is necessary to complete this block, delete “Period of Disability” and enter “Benefits.” The month of benefit termination is the second month after the month in which cessation occurs, e.g., ceased in 12/ 77, benefits terminated 02/78. Use a 4-digit figure to show both the cessation and benefit termination dates (MM/YY).

   Blocks D, E, F, G and H (following) relate to General Instructions in EPE cases.

4. Block D - Check this block to indicate the beginning month of an EPE (MM/YY). The “EPE Begin Month” begins with the month immediately following completion of the 9th month of trial work.

5. Block E - Check this block to indicate that EPE reinstatement is allowed. The “EPE Reinstatement Allowed” month is any month of non-SGA during the EPE.

6. Block F - Check this block to indicate that EPE reinstatement is denied.

7. Block G - Check this block to indicate that EPE is suspended after reinstatement. The “EPE Suspension After Reinstatement” month is the month a reinstated beneficiary returns to SGA during an EPE (show MM/YY).

8. Block H - (Complete only if the beneficiary is continuing to engage in SGA.) Check this block to indicate the benefit termination month (BTM) for EPE cases. The BTM is the first month for which disability benefits cannot be paid after the EPE, i.e., the month after the month in which the EPE ends (see DI 13010.210).

9. Block J - Instructions for completion of the items in this block are described in sections of this subchapter relating to specific case types.

K. Item 10 - basis for determination

Check block B or, if applicable, C. (See DI 10520.001 ff. for information concerning income related work expenses.)

L. Item 11 - reason for cessation and Item 12 - reason for continuance

In item 11, enter the appropriate code from the list in DI 41005.035, Exhibit 1. Codes from this list also apply to EPE cases where benefits are stopped (suspended) during an EPE.

In item 12, enter appropriate code from the list in DI 41005.035, Exhibit 2. Codes from this list also apply to EPE cases where benefits are reinstated during an EPE.

The medical listing number is completed only in DIB attainment cases when DIB is allowed or denied.

M. Item 13 - continuation sheet

Always check this block if attaching a continuation sheet. Form SSA-4268-U4 will be used as a continuation sheet in all cases upon depletion of the existing stock of SSA-834-U4 forms. (The SSA-834-U4 will no longer be used for this purpose and is being obsoleted.)

N. Item 14 - vocational rule

Leave blank.

O. Item 15

This block is completed only in work issue cases.

This block should reflect vocational background data regarding the beneficiary's customary occupation or, if not determined, the longest full-time occupation in the 15-year period prior to current adjudication. Show both the individual's occupation and the industry. Enter the appropriate 2 digit occupation code from DI 41005.035, Exhibit 3. Follow this code with a dash, and then enter the appropriate 2 digit industry code from DI 41005.035, Exhibit 4.

If a CDB has never had an occupation enter “None.” If there is no vocational information in the file, enter “unknown.”

P. Item 16 - occupational years

This block is completed in only work issue cases.

Show the number of years that the claimant worked in the customary occupation, if determined, or, if not determined, in the longest full-time occupation. When such information is not reflected on the SSA-3369-BK, it may appear elsewhere in the file. Where there are broken periods of employment in that occupation, determine the total number of years the individual was employed in the shown occupation. If the number of occupational years is unknown, enter “unk.”

Q. Item 17 - educational years

Enter the highest grade of school or college completed by beneficiary. If this is not available from the evidence in file, show “unk.”

R. Item 18 - special use

No entry required. Item 18 is for use upon specific instruction.

S. Item 20 - why review was made

Enter the appropriate code from DI 41005.035, Exhibit 5.

T. Items 21 and 22 - primary and secondary diagnosis

Extract the information (including both secondary and primary diagnoses as well as body system and ICD codes) from the most recent SSA-831-U5 or SSA-833-U5 in the file. If this information is not available, see 1. and 2. below.

1. Item 21 - primary diagnosis

Enter the primary diagnosis using DI 28084.035 as a guide. Show the diagnosis of statutory blindness in parenthesis.

a. Body system

In the block provided, enter the applicable body system code from the following list:

b. Code number

In the block provided, enter the impairment code number pertinent to the primary diagnosis. See DI 41005.035, Exhibit 6 for a list of impairment codes for visual impairments.

2. Item 22 - secondary diagnosis

Develop the secondary diagnosis using DI 28084.035 as a guide. Also, enter the impairment code number pertinent to the secondary diagnosis. If there is no secondary diagnosis, write “None” in the space.

U. Item 23 - diary

Establish an MIE diary if warranted, e.g., if surgery is scheduled, or an MINE diary as appropriate. Ordinarily a MIP diary would not be used.

In counting the months for diary maturity, start the count with the first month following the month that the SSA-833-U5 is signed, and show a 4 digit (MM /YY) date.

V. Item 24 - remarks

Enter any of the following remarks, if applicable. More than one remark may be entered. (The following list is not all inclusive.)

1. In DIB attainment - DIB allowed cases, show “Stat Blind - MOE to DIB (date).”

2. If the DIB, CDB, or DWB individual is age 55 or over and is engaging in comparable SGA, show “Beneficiary engaging in comparable SGA.”

3. If the DIB, CDB, or DWB individual is age 55 or over, is entitled to a TWP and has engaged in noncomparable SGA since the MOE, enter “Stat Blind Noncomparable SGA” and “Stat Blind WK - (Mo. &Yr. - On.” If work is not continuous, show each month and year of SGA.

4. If the “began” date in item 9 (J) (1) involves the first of the month, show “Date stat blindness began (date).”

5. If applicable, show the SSN on which the beneficiary has other entitlement, e.g., CDB or DWB.

6. Use a clarifying remark to explain any apparent inconsistency.

7. Where current evidence shows the individual is capable of handling funds and has a payee or is found incapable, show “claimant (in)capable per Dr.'s report dated .” Also, see DI 23001.001.

8. If the blind individual is legally competent, but has a representative payee enter “Blind Individuals address.”

9. When the beneficiary is represented by an attorney or other designated party, enter the name and address of the representative. The file should contain a statement by the beneficiary in all cases of approval of representative.

W. Items 24A, 24B, 25-28

Leave blank.

X. Item 29 - LTR/PAR no.

Instructions for completion of this item are in sections of this subchapter relating to specific case types.

Y. Items 30, 30A

Leave blank.

For instructions on signature requirements, see DI 26510.090C.

Z. Items 31-35

1. Item 31 - SSA Representative

   Sign the SSA-833-U5.

2. Item 32 - SSA Code

   Enter the appropriate code from following list:

3. Item 33 - Date

   Enter date of signature in item 31.

4. Item 34 - List No.

   See DI 33530.005 for a discussion of list codes. The specific code, where applicable, is to be entered in this item. If the disabled individual is permanently impaired, enter the related list code if the case has not been listed previously under that code.

5. Item 35 - Folder Sent To

   Designate where the folder is being routed. If case is routed to the Program Service Center (even if first routed to the DQB), show “NEPSC, MATPSC, SEPSC, GLPSC, MAMPSC, or WNPSC” as appropriate. If disability examiner action is required, route the case first to the DRS, e.g., NEPSC-DRS, MAPSC-DRS, etc.

The routing designation is for external routing only; i.e., if an ODO examiner routes to a benefit authorizer within ODO, no entry would be made. However, if he/she routed the folder to a PSC, he/she would enter that PSC.