BASIC (09-08)

A. Purpose of the Form SSA-1203

Use the Form SSA-1203 to record the amount payable after worker’s compensation/public disability benefit (WC/PDB) offset.

B. When to complete a paper SSA-1203

Complete a paper SSA-1203 only when you cannot use the Interactive Computations Facility (ICF) Function #32 – WC/PDB: Adjudicate Claim or #34 - Online Record Entry Operation (OREO).

Reference: MSOM ICFT2 028.001 - See ICF WC/PDB Function #28 for computation programs that produce the electronic version of the Form SSA-1203

C. Exhibit - Form SSA-1203

SSA-1203

D. Disposition of the SSA-1203

If the SSA-1203 cannot be stored or recorded in the Modernized Claims System (MCS), Modernized SSI Claims System (MSSICS), or the ICF, fax the form into the Non-Disability Repository for Evidentiary Documents (NDRED) or the electronic disability (eDIB) folder, as appropriate.

NOTE: If processing center (PC) action is required, the FO will also fax the form to the PC’s paperless fax number.

E. Completing the column sections of the SSA-1203

1. Enter the worker’s Social Security number and name.

2. Enter data for each new amount payable for each beneficiary.

   Such situations include:

   1. Change in the average current earnings (ACE), total family benefits (TFB), total WC benefits (TWCB) or total periodic benefits (TPB).

   2. Recomputation of the PIA.

   3. Cost-of-living increase.

   4. Any changes in the family composition.

   5. Offset change shown in right column.

   6. Triennial redetermination.

   7. Any other changes that affect the amount payable after offset.

3. Beneficiary Identification Code (BIC)

   1. Enter a separate BIC for each beneficiary.

   2. Enter HA in all initial DIB award or subsequent auxiliary situations; or in subsequent offset actions only if there is a change in the HA amounts payable.

4. Effective date

   1. Enter the month and year of the change (e.g., 05/1998, 02/1999-06/1999, 07/1999 on, etc.).

   2. Enter the rates through the current operating month (COM), plus one month.

   3. Diary via PCACS for any future month changes (e.g., ending date of LS). See DI 52165.005 for FO action to prepare the diary.

5. Benefit amount – Enter the full monthly benefit amounts before offset. For HA this is the PIA unless the worker was previously entitled to reduced retirement benefits.

6. Amount Payable – Show the amount payable that corresponds to the month in which the change occurred.

7. Current Workers’ Compensation Offset (CWCO)

   1. Enter the CWCO for each beneficiary due to WC only.

   2. Enter subsequent amounts if there is a change in the offset amount.

   3. Do not show amounts for months prior to December 1983.

   4. Enter zero if the offset type (OFT) is RJ, OP, ML, SG, or FM.

   NOTE: In most offset cases, the offset amount imposed against each auxiliary will be the same; however, in some cases (e.g., dually-entitled spouse, reduced spouse or divorced spouse) the offset amounts may differ.

8. Data entries for last four columns

   1. Enter Date, TFB, TWCB and TPB. (TWCB is zero for OFT – ML, SG or FM.).

   2. Enter this data for the first “Effective Date” shown and subsequent changes in TFB, TWCB, but not SSA COLAs.

F. Completing the offset coding section at the bottom of the SSA-1203

1. Offset Type (OFT)

• Code only the most recent OFT.

• Code ML, SG, FM, WL AND GW only for cases with a DIB onset of 03/01/1981 or later and an MOET of 09/1981 or later. PDB offset is not applicable in notice provision cases.

• Enter the SASP (State code) except those marked with an (*) and ACE for each OFT code. FM-SASP is the State of residence when federal PDB began.

• Use one of the following OFT codes:

• If WP and BL both apply, code BL.

• If RJ and OP both apply, code RJ.

NOTE: If the case involves both WC and PDB (OFT codes SW, WL and GW), the amount attributable only to WC must be broken out and shown separately so that the annual benefit statements will show the correct amount of taxable income.

Reference: For State and territory abbreviations, see RM 00499.003, Standardized Abbreviations of States and Outlying Areas of the United States.

2. Average Current Earnings (ACE)

Enter the original 80 percent ACE. If the ACE was recomputed in 02/1968 or 01/1973, due to amendments to the law or due to additional earnings, enter the latest original ACE. If an ACE increased due to a triennial redetermination, show the latest redetermined 80 percent ACE in the Remarks section.

3. Offset Effective Date (OED)

Enter the effective date OED (month/year), i.e., the first month offset is imposed or considered. For more information, see DI 52150.020 – Workers’ Compensation/Public Disability Benefits (WC/PDB) Offset Effective Date (OED).

4. Offset Termination Date (OTD)

Enter the OTD, if appropriate. This is the month/year no offset applies to the beneficiary. If offset was not imposed for one or more months due to RJ or OP, code an OTD if SSA becomes aware that the WC/PDB actually ended. For more information, see DI 52150.025 – Workers’ Compensation/Public Disability Benefits (WC/PDB) Offset Ending Date.

5. State Abbreviation-State Payment (SASP)

Enter the State’s 2-letter SASP code to indicate the State of political subdivision requiring the WC/PDB (usually the State where the injury or illness began). For State and territory abbreviations, see RM 00499.003, Standardized Abbreviations of States and Outlying Areas of the United States.

NOTE: Do not code the State of residence, unless offset code is FM.

Enter the applicable SASP code for all OFT codes except when the OFT code is FM, FC or HW.

6. Remarks

• Check the appropriate block(s).

• Enter the remark “Remove Offset – Not Applicable” if offset was imposed in error and is not applicable for any month.

• Enter the latest redetermined ACE only if it increased benefits payable. Complete the year in the “effective January” if a redetermined ACE applies.

• Enter the Civil Service Public Disability Benefit (CSPDB) indicator, if applicable. An indicator of “1” means CSPDB is offsettable and an indicator of “2” means CSPDB is not offsettable. See DI 52130.005 – Civil Service Retirement Systems (CSRS) Disability Benefits.

7. Signature

Sign and date the form. Then, scan or fax into the claims folder.