NL: Notices, Letters and Paragraphs
BASIC (05-11)
DTH009 LUMP-SUM DEATH PAYMENT INCLUDED WITH BENEFITS (B01)
(Requested)
Caption: What We Will Pay
(1) first check includes a lump-sum payment of (2) . This is a one-time payment we make because of a worker's death.
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 $$$$$.¢¢
Choice 1: Amount of LSDP
DTH010 LUMP SUM ONLY SURVIVOR BENEFITS SUSPENDED OR TERMINATED (B04)
(Requested)
Caption: What We Will Pay
(1) will soon receive a check for (2) . This is a one-time payment we make because of a worker's death. It is the only money (3) due now.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (2) - Systems Generated
Choice 1: Amount of LSDP
Fill-in (3) - Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
DTH011 COMBINED CHECK FOR MONTH OF DEATH WITHHELD FROM WIDOW(ER) RECEIVING FIRST BENEFIT PLUS LUMP-SUM (B05)
(Requested)
Caption: What We Will Pay
This check includes (1) , the money (2) due for (3) . It also includes a lump-sum payment of (4) . This is a one-time payment we make because of a worker's death.
We subtracted (5) from these benefits. We did this to recover money from the combined check which we sent for the month (6) died.
Fill-in values:
Fill-in (1) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Amount of past due benefits
Fill-in (2) - Systems Generated
Choice 1: you are
Choice 2: Beneficiary's Name +is
Fill-in (3) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (4) - Systems Generated
Choice 1: Amount of lump-sum
Fill-in (5) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Amount of reduction
Fill-in (6) - Systems Generated
Choice 1: Full name of NH
DTH012 CATEGORY M PAYMENT REASON AND AMOUNT - INTRODUCTORY PARAGRAPH (G58)
(System Generated)
Caption:
We are sorry to learn of (1) loss. Please accept our sincere sympathy.
(2) entitled to a Social Security payment because of the death of (3) . (4) will receive this payment soon.
The amount of the check is (5) .
Fill-in values:
Fill-in (1)
Choice 1: your
Choice 2: Beneficiary's Name possessive
Fill-in (2)
Choice 1: You are
Choice 2: He is
Choice 3: She is
Fill-in (3)
Choice 1: Name of deceased person
Fill-in (4)
Choice 1: You
Choice 2: He
Choice 3: She
Fill-in (5)
Choice 1: Amount of past due benefits