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NL: Notices, Letters and Paragraphs

Effective Dates: 02/09/2015 - Present

TN 30 (03-96)

Document Identifier for Word Processor: E3567

A. Exhibit letter

It has been determined that (1) is under a disability within the meaning of the disability insurance provisions of the Social Security Act.

This child is entitled to a monthly benefit of $ (2) beginning with the month of (3) . The next payment you receive will be in the amount of $ (4) and will represent payment for the month(s) of (5) . You will receive this payment (6) .

This claim will be reviewed from time to time to see if (7) is still eligible for benefits based on disability or blindness. When the claim is reviewed, you will be contacted if there is any question as to whether (8) eligibility continues.

3567A

If (1) goes to work while (2) is still disabled, (3) may be entitled to a trial work period to test (4) ability to work. During this period (5) may work in as many as 9 months (which need not be consecutive) and still receive disability benefit payments no matter how much (6) earns. After the trial work period is over, we will look at the work (7) did and we will decide whether (8) is still disabled.

However, the child is not entitled to a trial work period if:

  1. (9) is entitled to a period of disability but not to disability cash benefits; or

  2. (10) is receiving benefits for a second period of disability for which (11) did not have to complete a waiting period.

RESPONSIBILITIES OF PEOPLE RECEIVING DISABILITY BENEFITS

To prevent any incorrect payments, please notify us promptly if:

The child has already gone to work when you receive this notice; or if the child goes to work in the future, regardless of how much he/she earns. Other events you need to report are listed in the enclosed booklet entitled, “When You Get Social Security Disability Benefits...What You Need To Know.”

OR
3567B

Since (1) condition may improve, we have scheduled a review for
(2) . At that time, you will be contacted if there is any question as to whether (3) condition remains severe. Also, a review of the claim may be necessary if (4) goes to work.

If we do get in touch with you, we may ask you to give us more information or to have (5) take a medical examination. If we find (6) is still disabled, (7) benefits will continue. But, if the evidence obtained shows (8) is no longer disabled, the benefits will be stopped.

RESPONSIBILITIES OF PEOPLE RECEIVING DISABILITY
BENEFITS

To prevent any incorrect payments please notify us promptly if:

(9) has already gone to work when you receive this notice, or

(10) goes to work (regardless of how much (11) earns), or

(12) doctor advises you that (13) condition has improved and that (14) is able to work.

Other events you need to report are listed in the enclosed booklet entitled, “When You Get Social Security Disability Benefits...What You Need To Know.”

Read the enclosed instructions for important information and events which affect the payment of these benefits. You must notify the Social Security Administration promptly when any one of these events occurs.

 

If You Disagree With The Decision

ALS020

 

If You Have Any Questions

3901C - Domestic

3901D - Foreign

 

Enclosure:
SSA Pub. No. 05-10153

B. Requesting instructions

  • This notice is used in the same situation as Exhibit NL 00703.566, except that the child has a representative payee.

  • Paragraph 3567A will be used when a medical reexam is not being scheduled. Paragraph 3567B will be used when a medical reexam is being scheduled.

  • Refer to NL 00703.005E. for 3901C and 3901D text. Refer to NL 00703.180 for 3180A and 3180B text.

     

Fill-ins:

  1. name of the child

  2. the monthly benefit amount

  3. the month he/she attained age 18

  4. the amount of the next check

  5. the inclusive months for which payment is being made in the next check

  6. the words “shortly after” followed by the date of the next check

  7. he, she

  8. name of the child

     

Paragraph 3567A

  1. name of the child

  2. he, she

  3. he, she

  4. his, her

  5. he, she

  6. he, she

  7. he, she

  8. he, she

  9. he, she

  10. he, she

  11. he, she

     

Paragraph 3567B

  1. name of the child, possessive

  2. date on which medical reexam has been scheduled

  3. his, her

  4. he, she

  5. name of the child

  6. he, she

  7. his, her

  8. he, she

  9. he, she

  10. he, she

  11. he, she

  12. his, her

  13. his, her

  14. he, she

C. Typing instructions

Information for this letter will be shown on Form SSA-573. The name and address, if not given, can be taken from the latest Form SSA-3926-EP in file.

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