NL: Notices, Letters and Paragraphs
TN 7 (10-16)
ADJ015 AERO UNDERPAYMENT IN EXCESS OF $30,000.00 (A03)
(Requested)
Caption: What We Will Pay
(1) may owe Federal income tax on this back payment. To find out, contact the Internal Revenue Service. They can answer (2) Federal income tax questions and provide (3) with additional information about computing such tax. If (4) any questions about the amount of back payment, or if (5) a yearly breakdown of this payment, contact us. Our telephone number and address are shown below.
Fill-in values:
Fill-in (1) - Systems Generated:
Choice 1: You
Choice 2: Beneficiary's Name
Fill-in (2) - Systems Generated:
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3) - Systems Generated:
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (4) - Systems Generated:
Choice 1: you have
Choice 2: he has
Choice 3: she has
Fill-in (5) - Systems Generated:
Choice 1: you need
Choice 2: he needs
Choice 3: she needs
ADJ016 AUXILIARY'S BENEFIT CHANGED BY ONE RECOMPUTATION (A13)
(Requested)
Caption: Your Benefits
We changed (1) monthly benefit beginning (2) because we raised (3) (4) benefit.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your
Choice 2: Beneficiary's Name possessive
Fill-in (2) - Requested As A Date In Format In Format Shown Below
Choice 1: Date benefit amount changed (MM/CCYY format)
Fill-in (3) - System Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (4) - Requested As A One Position Alpha Character
Choice 1: (A) husband's
Choice 2: (B) wife's
Choice 3: (C) former husband's
Choice 4: (D) former wife's
Choice 5: (E) father's
Choice 6: (F) mother's
ADJ017 PARTIAL ADJUSTMENT APPROVED COMPLETELY (A30)
(Requested)
Caption: Your Benefits
As (1) asked, we will withhold money from (2) checks to collect the (3) of (4) . We will withhold (5) each month for (6) months beginning (7) (8) . After we collect the money, we will raise (9) benefits back to (10) regular monthly payment amount.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you
Choice 2: beneficiary's name
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3) - Requested As A One Position Alpha Character
Choice 1: (A) overpayment
Choice 2: (B) penalty
Choice 3: (C) overpayment and penalty
Fill-in (4) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Amount of overpayment
Fill-in (5) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Amount of partial withholding
Fill-in (6) - Requested As A Number
Choice 1: Number of months the partial amount will be withheld (exclude fractions)
Fill-in (7) - Requested As A Date In Format MM/CCYY
MM/CCYY
Fill-in (8) - Requested As A One Position Alpha Character
Choice 1: (A) null
Choice 2: (B) and withhold the remaining amount due from
the first monthly check we pay after that
Fill-in (9) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (10) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
ADJ018 PARTIAL ADJUSTMENT APPROVED AT A RATE MORE THAN REQUESTED (A31)
(Requested)
Caption: Your Benefits
(1) asked us to use a lower rate when we withhold the money from (2) checks to collect (3) (4) . We decided to withhold more than (5) requested, so that we can recover the overpayment in a shorter time.
We will withhold (6) per month for (7) months beginning (8) (9) . After we have recovered (10) , we will raise (11) benefits back to (12) regular monthly amount.
Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's name
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (4) - Requested As A One Position Alpha Character
Choice 1 (A): overpayment
Choice 2 (B): penalty
Choice 3 (C): overpayment and penalty
Fill-in (5) - System generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (6) - Requested As A Money Amount In Format $$$$$.¢¢
Amount of partial withholding
Fill-in (7) Requested As A Number
Number of months of partial withholding in effect
Fill-in (8) - Requested As A Date In Format Shown Below
MM/CCYY
Fill-in (9) - Requested As A One Position Alpha Character
Choice 1 (A): null
Choice 2 (B): and withhold the remaining amount due from the first monthly check we pay after that
Fill-in (10) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Amount of overpayment
Fill-in (11) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (12) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
ADJ019 FINAL ADJUSTMENT - FRACTION OF A MONTH (A32)
(Requested)
Caption: Your Benefits
We are withholding (1) from (2) benefits. This is the last money (3) owed because of (4) overpayment.
Fill-in values:
Fill-in (1) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Amount withheld
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: Beneficiary's Name
Fill-in (3) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
ADJ020 DUAL ENTITLEMENT AWARD - PRIMARY AND AUXILIARY/SURVIVOR BENEFITS AWARDED SIMULTANEOUSLY - CHECKS COMBINED (A39)
(Requested)
Caption: What We Will Pay
(1) benefit is (2) on (3) earnings record and (4) as a (5) .
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Your
Choice 2: Beneficiary's Name possessive
Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Amount MBP after any SMI deductions and rounding from SAMBA
Fill-in (3) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (4) - Requested As A Money Amount In Format $$$$$.¢¢
Amount MBP this is LEMBA after rounding
Fill-in (5) - Requested As A One Position Alpha Character
Choice 1: (A) wife
Choice 2: (B) husband
Choice 3: (C) widow
Choice 4: (D) widower
Choice 5: (E) disabled widow
Choice 6: (F) disabled widower
Choice 7: (G) child
Choice 8: (H) mother
Choice 9: (I) father
ADJ021 DUAL ENTITLEMENT - AUXILIARY/SURVIVOR AWARD AFTER PRIMARY - SEPARATE PAYMENTS (A43)
(Requested)
Caption: What We Will Pay
This is in addition to the benefit on (1) own earnings record.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Choice 4: Beneficiary's Name possessive
ADJ022 BENEFITS RESUMED EFFECTIVE WITH DATE OF RECONSIDERATION OR WAIVER REQUEST - PROTEST DATED PRIOR TO EXPIRATION OF RECONSIDERATION (60 DAYS) (LAF D to LAF C ) (A45)
(Requested)
Caption: Your Benefits
We are paying (1) again beginning (2) because (3) asked us to review our overpayment decision. For now, we are still withholding the money which we already subtracted from (4) checks.
If we later find that our decision was correct, or that we cannot waive the overpayment, (5) will have to pay back the (6) which (7) . Someone from the local Social Security office will contact (8) to talk about the overpayment.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you
Choice 2: beneficiary's name
Fill-in (2) – Requested As A Date In Format Shown Below
Date payments resume (MM/CCYY format)
Fill-in (3) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (6) - Requested As A Money Amount In Format $$$$$.¢¢
Balance of overpayment
Fill-in (7) - Systems Generated
Choice 1: you owe
Choice 2: he owes
Choice 3: she owes
Fill-in (8) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
ADJ023 ENTITLEMENT CONVERSION — DIB TO RSI (A01)
(Requested)
Caption: Your Benefits
Because (1) reached (2) (3) , we are changing (4) disability benefits to (5) benefits beginning (6) .
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you have
Choice 2: Beneficiary's name has
Fill-in (2) - Requested As A One Position Alpha Character
Choice 1: (A) age 65
Choice 2: (B) full retirement age
Fill-in (3) - Systems Generated
Choice 1: null
Choice 2: 65 years
Choice 3: Full Retirement Age as determined from FRA
utility, displayed in format: 65 and 2 months
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) - Requested As A One Position Alpha Character
Choice 1: (A) retirement
Choice 2: (B) widow's
Choice 3: (C) widower's
Fill-in (6) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY of entitlement conversion
ADJ024 CHECK PARAGRAPH ADJUSTMENT NOTICE (GA2)(G16)
(System Generated)
Caption: What We Will Pay
The next check (1) will be for (2) , which is the money (3) due through (4) .
(5) next scheduled payment of (6) , which is for (7) , will be received on or about the (8) of (9) .
After that, (10) will receive (11) on or about the (12) of each month.
Fill-in values:
Fill-in (1)
Choice 1: you receive
Choice 2: Beneficiary Name receives
Fill-in (2)
PAMT (PMA)
Fill-in (3)
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (4)
COM minus 1 month in MM/CCYY format
Fill-in (5)
Choice 1: Your
Choice 2: His
Choice 3: Her
Fill-in (6)
CMA
Fill-in (7)
COM in MM/CCYY format
Fill-in (8) - Systems Generated
Choice 1: If PCI on the MBR = 1, generate third
Choice 2: If PCI on the MBR = 2, generate second Wednesday
Choice 3: If PCI on the MBR = 3, generate third Wednesday
Choice 4: If PCI on the MBR = 4, generate fourth Wednesday
Fill-in (9)
COM plus 1 month in MM/CCYY format
Fill-in (10)
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (11)
MBP
Fill-in (12)
Choice 1: If PCI on the MBR = 1, generate third
Choice 2: If PCI on the MBR = 2, generate second Wednesday
Choice 3: If PCI on the MBR = 3, generate third Wednesday
Choice 4: If PCI on the MBR = 4, generate fourth Wednesday
ADJ025 CHECK PARAGRAPH ADJUSTMENT NOTICE (GA1)(G16)
(System Generated)
Caption: What We Will Pay
The next check (1) will be for (2) , which is the money (3) due through (4) .
After that, (5) will receive (6) , on or about the (7) of each month.
Fill-in values:
Fill-in (1)
Choice 1: you receive
Choice 2: beneficiary's name receives
Fill-in (2)
CAMT (CMA)
Fill-in (3)
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (4)
COM in MM/CCYY format
Fill-in (5)
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (6)
MBP
Fill-in (7)
Choice 1: third
Choice 2: second Wednesday
Choice 3: third Wednesday
Choice 4: fourth Wednesday
ADJ027 A20 EXPLANATION (old G50/AB5)/(old A02/AA1)
(Requested)
Caption: Your Benefits
We (1) the monthly benefit amount beginning (2) (3) .
Fill-in values:
Fill-in (1) - Requested As A One Position Alpha Character
Choice 1 (A): raised
Choice 2 (B): reduced
Choice 3 (C): changed
Fill-in (2) - Requested As A Date In Format Shown Below
MM/CCYY
Fill-in (3) - Requested As A One Position Alpha Character
Choice 1 (C): because we stopped paying another person on this record
Choice 2 (D): because we started paying another person on this record
Choice 3 (M): because of a change in the way we compute benefits when someone is entitled on more than one Social Security record
Choice 4 (O): because the cost of living increased
ADJ028 CHANGE IN BENEFIT RATE – RECOMP (A02) (AA6)
(Requested)
Caption: Your Benefits
We (1) the monthly benefit beginning (2) because we could pay (3) for more months after (4) reached (5) (6) than we previously used when we figured (7) benefit.
Fill-in values:
Fill-in (1) - Requested As A One Position Alpha Character
Choice 1: (A) raised
Choice 2: (B) reduced
Choice 3: (C) changed
Fill-in (2) - Requested As A Date In Format MM/CCYY
MM/CCYY effective date of change
Fill-in (3) - Systems Generated
Choice 1: you
Choice 2: beneficiary's name
Fill-in (4) - Systems Generated Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (5) - Requested As A One Position Alpha Character
Choice 1: (A) age 65
Choice 2: (B) full retirement age
Fill-in (6) System Generated
Choice 1: Full Retirement Age as determined from FRA utility, displayed in format: 65 and 2 months
Choice 2: Null
Fill-in (7) - System Generated
Choice 1: your
Choice 2: his
Choice 3: her
ADJ029 CHANGE IN BENEFIT RATE DUE TO SPOUSE'S DEATH (A02) (AA7)
(Requested)
Caption: Your Benefits
We (1) the monthly benefit beginning (2) because of the death of (3) .
Fill-in values:
Fill-in (1) - Requested As A One Position Alpha Character
Choice 1 (A): raised
Choice 2 (B): reduced
Choice 3 (C): changed
Fill-in (2) – Requested As A Date In Format MM/CCYY
MM/CCYY effective date of change
Fill-in (3) - Requested As A Language
Name of deceased spouse
ADJ032 CHANGE IN BENEFIT RATE TO CREDIT MONTHS DECEASED SPOUSE NOT PAID (A02) (AA3)
(Requested)
Caption: Your Benefits
We (1) the monthly benefit beginning (2) to give (3) credit for months when we did not pay full benefits to (4) .
Fill-in values:
Fill-in (1) - Requested As A One Position Alpha Character
Choice 1: (A) raised
Choice 2: (B) reduced
Choice 3: (C) changed
Fill-in (2) - Requested As A Date In Format Shown Below
MM/CCYY effective date of change
Fill-in (3) - Systems Generated
Choice 1: you
Choice 2: beneficiary's name
Fill-in (4) - Requested As A Language
Name of deceased spouse
ADJ035 CHANGE IN BENEFIT RATE – RECEIPT OF OTHER PENSION (A02)(AA9)
(Requested)
Caption: Your Benefits
We (1) the monthly benefit beginning (2) because the pension (3) from (4) no longer (5) (6) Social Security benefits.
Fill-in values:
Fill-in (1) - Requested As A One Position Alpha Character
Choice 1: (A) raised
Choice 2: (B) reduced
Choice 3: (C) changed
Fill-in (2) - Requested As A Date In Format Shown Below
MM/CCYY effective date of change
Fill-in (3) - Systems Generated
Choice 1: Beneficiary's name gets
Choice 2: you get
Fill-in (4) - Requested As A Language
Name of the agency paying pension
Fill-in (5) - Requested As A One Position Alpha Character
Choice 1 (A): reduces
Choice 2 (B): affects the way we figure
Fill-in (6) - Systems Generated
Choice 1: his
Choice 2: her
Choice 2: your
ADJ037 CHANGE IN BENEFIT RATE – FRA (A02) (AB2)
(Requested)
Caption: Your Benefits
We (1) the monthly benefit beginning (2) because we could pay (3) at the full rate for more months before (4) (5) than we previously used when we figured (6) benefit.
Fill-in values:
Fill-in (1) - Requested As A One Position Alpha Character
Choice 1: (A) raised
Choice 2: (B) reduced
Choice 3: (C) changed
Fill-in (2) - Requested As A Date In Format Shown Below
MM/CCYY effective date of change
Fill-in (3) - Systems Generated
Choice 1: Beneficiary's Name
Choice 2: you
Fill-in (4) - Requested As A One Position Alpha Character
Choice 1: (A) age 65
Choice 2: (B) full retirement age
Fill-in (5) - Systems Generated
Choice 1: Full Retirement Age as determined from FRA utility, displayed in format: 65 and 2 months
Choice 2: Null
Fill-in (6) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
ADJ038 NAME: EXPLANATION – CHILD IN CARE RECEIVING BENEFITS (G50) (AB6)
(Requested)
Caption: Your Benefits
We raised the monthly benefit amount beginning (1) to give (2) credit for months before (3) reached (4) when (5) caring for a child who was receiving benefits.
Fill-in values:
Fill-in (1) - Requested As A Date In Format Shown Below
MM/CCYY
Fill-in (2) - Systems Generated
Choice 1: you
Choice 2: beneficiary's name
Fill-in (3) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (4) - Systems Generated
Choice 1: age 65
Choice 2: full retirement age
Fill-in (5) - Systems Generated
Choice 1: you were
Choice 2: he was
Choice 3: she was
ADJ039 EXPLANATION – RAISED SURVIVOR BENEFITS DUE TO WORK AND EARNINGS (G50) (AB7)
(Requested)
Caption: Your Benefits
We raised the monthly benefit amount beginning (1) to give (2) credit for months when (3) was entitled to full benefits but did not receive them because of work and earnings.
Fill-in values:
Fill-in (1 - Requested As A Date In Format Shown Below
MM/CCYY
Fill-in (2) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's name
Fill-in (3) - Requested As A Language
Choice 1: Name of deceased spouse
ADJ041 NAME: EXPLANATION – EARNED LESS THAN ESTIMATE (G50) (AB9)
(Requested)
Caption: Your Benefits
We raised the monthly benefit amount beginning (1) because (2) earned less money after (3) reached (4) than (5) originally estimated.
Fill-in values:
Fill-in (1 - Requested As A Date In Format Shown Below
MM/CCYY
Fill-in (2) - Systems Generated
Choice 1: you
Choice 2: beneficiary's name
Fill-in (3) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (4) - Requested As A One Position Alpha Character
Choice 1: (A) age 65
Choice 2: (B) full retirement age
Fill-in (5) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
ADJ043 EXPLANATION – CREDIT FOR DECEASED SPOUSE'S EARNINGS (old G50/AC1)/ (old A02/AA5)
(Requested)
Caption: Your Benefits
We raised the monthly benefit amount beginning (1) to give (2) credit for months when (3) reached (4) but did not receive benefits because of work and earnings.
Fill-in values:
Fill-in (1) - Requested As A Date In Format Shown Below
MM/CCYY
Fill-in (2) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's name
Fill-in (3) - Requested As A Language
Name of deceased spouse
Fill-in (4) - Systems Generated
Choice 1: age 65
Choice 2: full retirement age
Fill-in (5) - Systems Generated
Choice 1: full retirement age as determined from FRA utility, displayed in format 65 and 2 months
Choice 2: null
ADJ044 EXPLANATION – CREDIT FOR NOT RECEIVING BENEFITS (olsG50/AC2)/(old A02/AA8)
(Requested)
Caption: Your Benefits
We raised the monthly benefit amount beginning (1) to give (2) credit for months when (3) reached (4) (5) and did not receive a retirement benefit.
Fill-in values:
Fill-in (1) - Requested As A Date In Format Shown Below
MM/CCYY
Fill-in (2) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's name
Fill-in (3) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (4) - Systems Generated
Choice 1: age 65
Choice 2: full retirement age
Fill-in (5) - Systems Generated
Choice 1: full retirement age as determined from FRA utility, displayed in format 65 and 2 months
Choice 2: null
ADJ045 EXPLANATION – ARF ADJUSTMENT (G50) (AC3)
(Requested)
Caption: Your Benefits
We raised the monthly benefit amount beginning (1) to give (2) credit for benefits, which we did not pay at the full rate before (3) reached (4) (5) . This was because of (6) work and earnings.
Fill-in values:
Fill-in (1) - Requested As A Date In Format Shown Below
MM/CCYY
Fill-in (2) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's name
Fill-in (3) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (4) - Systems Generated
Choice 1: age 65
Choice 2: full retirement age
Fill-in (5) - Systems Generated
Choice 1: FRA years + FRA months
Choice 2: null
Fill-in (6) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
ADJ046 AWARD CHECK PARAGRAPH DIRECT DEPOSIT (G92) (G03)
(System Generated)
Caption: What We Will Pay
(1) first check is for (2) .
This is the money (3) due through (4) .
After that, (5) will receive (6) on or about the (7) of each month (8) monthly payments will go to the financial institution (9) selected.
Fill-in values:
Fill-in (1)
Choice 1: Your
Choice 2: His
Choice 3: Her
Choice 4: Beneficiary name possessive
Fill-in (2)
PMA
Fill-in (3)
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (4)
COM in MM/CCYY format
Fill-in (5)
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (6)
MBP
Fill-in (7)
Choice 1: third
Choice 2: second Wednesday
Choice 3: third Wednesday
Choice 4: fourth Wednesday
Fill-in (8)
Choice 1: Your
Choice 2: His
Choice 3: Her
Fill-in (9)
Choice 1: you
ADJ047 AWARD CHECK PARAGRAPH DIRECT DEPOSIT (G93) (G03)
(System Generated)
Caption: What We Will Pay
(1) first payment is for (2) .
This is the money (3) due through (4) .
(5) next scheduled payment of (6) , which is for (7) , will be received on or about the (8) of (9) .
After the first payment, (10) will receive (11) on or about the (12) of each month.
(13) monthly payments will go to the financial institution (14) selected.
Fill-in values:
Fill-in (1)
Choice 1: Your
Choice 2: His
Choice 3: Her
Choice 4: Beneficiary name possessive
Fill-in (2)
PMA
Fill-in (3)
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (4)
COM minus 1 month in MM/CCYY format
Fill-in (5)
Choice 1: Your
Choice 2: His
Choice 3: Her
Fill-in (6)
CMA
Fill-in (7)
COM in MM/CCYY format
Fill-in (8)
Choice 1: third
Choice 2: second Wednesday
Choice 3: third Wednesday
Choice 4: fourth Wednesday
Fill-in (9)
COM plus 1 month in MM/CCYY format
Fill-in (10)
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (11)
MBP
Fill-in (12)
Choice 1: third
Choice 2: second Wednesday
Choice 3: third Wednesday
Choice 4: fourth Wednesday
Fill-in (13)
Choice 1: Your
Choice 2: His
Choice 3: Her
Fill-in (14)
Choice 1: you
ADJ048 A18 NOTICE - CHECK PARAGRAPH AC5 (G56)
(System Generated)
Caption: What We Will Pay
(1) will soon receive a check for payment of (2) because we owed money to (3) . This payment is in addition to any monthly payments (4) may receive.
Fill-in values:
Fill-in (1)
Choice 1: You
Choice 2: Beneficiary's name
Fill-in (2)
Amount
Fill-in (3) Requested by the Tech
Name of deceased beneficiary
Fill-in (4) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
ADJ049 A18 NOTICE–CHECK PARAGRAPH FOR MEDICARE REFUND AC6(G56)
(System Generated)
Caption: What We Will Pay
(1) will soon receive a check for (2) because (3) due a refund of (4) Medicare prescription drug plan costs.
Fill-in values:
Fill-in (1)
Choice 1: You
Choice 2: Beneficiary's Name
Fill-in (2)
Amount
Fill-in (3)
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (4)
Choice 1: your
Choice 2: his
Choice 3: her
ADJ050 EXPLANATION (G50)
(Requested)
Caption: Your Benefits
We (1) the monthly benefit amount beginning (2) to give (3) credit for additional earnings.
Fill-in values:
Fill-in (1) - Requested As A One Position Alpha Character
Choice 1: (A) raised
Choice 2: (B) reduced
Fill-in (2) - Requested As A Date In Format Shown Below
MM/CCYY
Fill-in (3) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's name
ADJ051 EXPLANATION (G50)
(Requested)
Caption: Your Benefits
We (1) the monthly benefit amount beginning (2) to give (3) credit for a period of disability.
Fill-in values:
Fill-in (1) - Requested As A One Position Alpha Character
Choice 1: (A) raised
Choice 2: (B) reduced
Fill-in (2) - Requested As A Date In Format Shown Below
MM/CCYY
Fill-in (3) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's name
ADJ052 EXPLANATION (G50)
(Requested)
Caption: Your Benefits
We (1) the monthly benefit amount beginning (2) to give (3) credit for months when we did not pay at the full rate before (4) reached age 62. This was because of (5) work and earnings.
Fill-in values:
Fill-in (1) - Requested As A One Position Alpha Character
Choice 1: (A) raised
Choice 2: (B) reduced
Fill-in (2) - Requested As A Date In Format Shown Below
MM/CCYY
Fill-in (3) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's name
Fill-in (4) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (5) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
ADJ053 EXPLANATION (G50)
(Requested)
Caption: Your Benefits
We (1) the monthly benefit amount beginning (2) to correct (3) benefit amount.
Fill-in values:
Fill-in (1) - Requested As A One Position Alpha Character
Choice 1: (A) raised
Choice 2: (B) reduced
Fill-in (2) - Requested As A Date In Format Shown Below
MM/CCYY
Fill-in (3) - Systems Generated
Choice 1: your
Choice 2: Beneficiary's name possessive
ADJ054 AWARD CHECK PARAGRAPH GENERAL G89 (G02)
(System Generated)
Caption: What We Will Pay
(1) first check is for (2) .
This is the money (3) due through (4) .
After that, (5) will receive (6) on or about the (7) of each month.
Fill-in values:
Fill-in (1)
Choice 1: Your
Choice 2: Beneficiary's name possessive
Fill-in (2)
PMA in format $$$$$.¢¢
Fill-in (3)
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (4)
COM in MM/CCYY format
Fill-in (5)
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (6)
MBP in format $$$$$.¢¢
Fill-in (7)
Choice 1: If PCI on the MBR = 1, generate third
Choice 2: If PCI on the MBR = 2, generate second Wednesday
Choice 3: If PCI on the MBR = 3, generate third Wednesday
Choice 4: If PCI on the MBR = 4, generate fourth Wednesday
ADJ055 AWARD CHECK PARAGRAPH GENERAL G90 (G02)
(System Generated)
Caption: What We Will Pay
(1) first check is for (2) .
This is the money (3) due through (4) .
(5) next scheduled payment of (6) which is for (7) , will be received on or about the (8) of (9) .
After that, (10) will receive (11) on or about the (12) of each month.
Fill-in values:
Fill-in (1)
Choice 1: Your
Choice 2: Beneficiary's Name possessive
Fill-in (2)
PMA in format $$$$$.¢¢
Fill-in (3)
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (4)
COM minus 1 month in MM/CCYY format
Fill-in (5)
Choice 1: Your
Choice 2: His
Choice 3: Her
Fill-in (6)
CMA in format $$$$$.¢¢
Fill-in (7)
COM in MM/CCYY format
Fill-in (8)
Choice 1: If PCI on the MBR = 1, generate third
Choice 2: If PCI on the MBR = 2, generate Second Wednesday
Choice 3: If PCI on the MBR = 3, generate third Wednesday
Choice 4: If PCI on the MBR = 4, generate fourth Wednesday
Fill-in (9)
COM plus 1 month in MM/CCYY format
Fill-in (10)
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (11)
MBP in format $$$$$.¢¢
Fill-in (12)
Choice 1: If PCI on the MBR = 1, generate third
Choice 2: If PCI on the MBR = 2, generate second Wednesday
Choice 3: If PCI on the MBR = 3, generate third Wednesday
Choice 4: If PCI on the MBR = 4, generate fourth Wednesday
ADJ056 EXPLANATION (AA1)
(Requested)
Caption: Your Benefits
We (1) the monthly benefit beginning (2) because we changed the month when (3) first due benefits.
Fill-in values:
Fill-in (1) - Requested As A One Position Alpha Character
Choice 1: (A) raised
Choice 2: (B) reduced
Choice 3: (C) changed
Fill-in (2) - Requested As A Date In Format Shown Below
MM/CCYY
Fill-in (3) - Systems Generated
Choice 1: you were
Choice 2: Beneficiary's name was
ADJ057 EXPLANATION (AA1)
(Requested)
Caption: Your Benefits
We (1) the monthly benefit beginning (2) , because we could pay (3) at the full rate for more months before age 62 than we previously used when we figured (4) benefits
Fill-in values:
Fill-in (1) - Requested As A One Position Alpha Character
Choice 1: (A) raised
Choice 2: (B) reduced
Choice 3: (C) changed
Fill-in (2) - Requested As A Date In Format Shown Below
MM/CCYY
Fill-in (3) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's name
Fill-in (4)
Choice 1: your
Choice 2: his
Choice 3: her
ADJ058 CHECK PARAGRAPH G56. A18 NOTICE (AC4)
(System Generated)
Caption: What We Will Pay
(1) will soon receive a check for (2) because (3) .
Fill-in values:
Fill-in (1)
Choice 1: You
Choice 2: Beneficiary name
Fill-in (2)
Amount in format $$$$$.¢¢
Fill-in (3)
Choice 1: (A) of an additional lump-sum payment
Choice 2: (D) of a rate increase
Choice 3: (E) a former payee returned a check
Choice 4: (H) we are refunding excess premiums for medical insurance
Choice 5: (I) of a returned benefit check
Choice 6: (L) we were withholding money to pay an attorney fee, and no fee was charged
Choice 7: (O) a former payee returned checks
ADJ059 CHECK PARAGRAPH G56. A18 NOTICE (AC4)
(System Generated)
Caption: What We Will Pay
(1) will soon receive a check for (2) because we had withheld money from (3) benefits.
Fill-in values:
Fill-in (1)
Choice 1: You
Choice 2: Beneficiary name
Fill-in (2)
Amount
Fill-in (3)
Choice 1: your
Choice 2: his
Choice 3: her
ADJ060 CHECK PARAGRAPH G56. A18 NOTICE (AC4)
(System Generated)
Caption: What We Will Pay
(1) will soon receive a check for (2) because (3) due money in addition to (4) regular monthly benefit check.
Fill-in values:
Fill-in (1)
Choice 1: You
Choice 2: Beneficiary name
Fill-in (2)
Amount
Fill-in (3)
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (4)
Choice 1: your
Choice 2: his
Choice 3: her
ADJ061 CHECK PARAGRAPH G56. A18 NOTICE (AC4)
(System Generated)
Caption: What We Will Pay
(1) will soon receive a check for (2) because we withheld money from (3) benefits due to (4) work or earnings.
Fill-in values:
Fill-in (1)
Choice 1: You
Choice 2: Beneficiary name
Fill-in (2)
Amount in format $$$$$.¢¢
Fill-in (3)
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (4)
Choice 1: your
Choice 2: his
Choice 3: her
ADJ062 CHECK PARAGRAPH G56. A18 NOTICE (AC4)
(System Generated)
Caption: What We Will Pay
(1) will soon receive a check for (2) because (3) eligible for provisional benefits.
Fill-in values:
Fill-in (1)
Choice 1: You
Choice 2: Beneficiary name
Fill-in (2)
Amount in format $$$$$.¢¢
Fill-in (3)
Choice 1: you are
Choice 2: he is
Choice 3: she is
ADJ063 CHECK PARAGRAPH G56. A18 NOTICE (AC4)
(System Generated)
Caption: What We Will Pay
(1) will soon receive a check for (2) because (3) sent us too much money when (4) refunded (5) overpayment.
Fill-in values:
Fill-in (1)
Choice 1: You
Choice 2: Beneficiary name
Fill-in (2)
Amount in format $$$$$.¢¢
Fill-in (3)
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (4)
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (5)
Choice 1: your
Choice 2: his
Choice 3: her
ADJ064 CHECK PARAGRAPH G56. A18 NOTICE (AC4)
(System Generated)
Caption: What We Will Pay
(1) will soon receive a check for (2) because we are sending (3) money which we did not have to use to pay an attorney fee.
Fill-in values:
Fill-in (1)
Choice 1: You
Choice 2: Beneficiary name
Fill-in (2)
Amount in format $$$$$.¢¢
Fill-in (3)
Choice 1: your
Choice 2: his
Choice 3: her