NL: Notices, Letters and Paragraphs
BASIC (05-11)
AGE006 DATE OF BIRTH HAS NOT BEEN ESTABLISHED FOR MEDICARE COVERAGE (Q23)
(Requested)
Caption: Information About Medicare
(1) (2) not qualify for (3) now because we have not received enough evidence
to prove that (4) reached age (5) . If you can furnish additional proof of (6) age, please contact any Social Security office promptly.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: You
Choice 2: Mr. + Beneficiary's Last Name
Choice 3: Ms. + Beneficiary's Last Name
Fill-in (2) - Systems Generated
Choice 1: do
Choice 2: does
Fill-in (3) - Systems Generated
Choice 1: retirement benefits
Choice 2: disability
Choice 3: spouse's benefits
Choice 4: widow's benefits
Choice 5: widower's benefits
Choice 6: parent's benefits
Choice 7: disabled widow's benefits
Choice 8: disabled widower's benefits
Choice 9: Medicare
Fill-in (4) - Systems Generated
Choice 1: you have
Choice 2: he has
Choice 3: she has
Fill-in (5) - Systems Generated
Choice 1: 62
Choice 2: 50
Choice 3: 60
Choice 4: 65
Fill-in (6) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
AGER09 DEVELOPMENT OF FOREIGN BIRTH RECORD (C20)
(Requested)
Caption: The Basis For Our Decision
To pay benefits more quickly, we used (1) as (2) date of birth. This date is based on the documents (3) gave us. We are still waiting for a copy of the foreign birth record. If the foreign birth record does not agree with the date of birth we used, we may need to revise our decision about (4) date of birth. A different date of birth could affect your right to benefits or the amount of your payments. Also, if we paid you too much, you may have to pay us back. When we receive the foreign birth record, we will send you another letter to let you know if there will be a change in your payments.
Fill-in values:
Fill-in (1) - Requested As A Date In Format Shown Below
Alleged date of birth in the format MM/DD/CCYY
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: Beneficiary's name possessive
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