NL: Notices, Letters and Paragraphs
TN 8 (09-17)
WCP001 NUMBERHOLDER EXPRESSED INTENT TO FILE FOR WORKERS' COMPENSATION, ANOTHER DISABILITY PAYMENT OR BOTH (J59)
(Requested)
Caption: Information About Other Disability Benefits
We learned that (1) to file a claim for workers' compensation and/or public disability benefit. If (2) these payments, we may have to reduce (3) Social Security benefits.
At that time, (4) may have to pay back any Social Security benefits that (5) not due. If (6) a claim, please tell us the decision made on the claim right away.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Number Holder's full name plans
Choice 2: you plan
Fill-in (2) - Systems Generated
Choice 1: you receive
Choice 2: he receives
Choice 3: she receives
Fill-in (3) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Choice 4: your and your family's
Choice 5: his and his family's
Choice 6: her and her family's
Fill-in (4) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Choice 4: you and your family
Choice 5: he and his family
Choice 6: she and her family
Fill-in (5) - Systems Generated
Choice 1: you were
Choice 2: he was
Choice 3: she was
Choice 4: you and your family were
Choice 5: he and his family were
Choice 6: she and her family were
Fill-in (6) - Systems Generated
Choice 1: you file
Choice 2: he files
Choice 3: she files
WCP003 DEFINITION OF WORKERS' COMPENSATION OFFSET (J48)
(Requested)
Caption: Information About Other Disability Benefits
We have to consider workers' compensation and/or public disability payments when we figure a Social Security benefit. The following will explain how these payments affect Social Security benefits. For more information, please read the enclosed pamphlet, "How Workers' Compensation and Other Disability Payments May Affect Your Social Security Benefit."
WCP004 NUMBERHOLDER RECEIVING WORKERS' COMPENSATION OR OTHER DISABILITY PAYMENTS - NO OFFSET (J44)
(Requested)
Caption: Your Benefits
(1) present (2) payments of (3) do not affect (4) Social Security benefits.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: NH Name possessive
Choice 2: Your
Fill-in (2) - Requested As A One Position Alpha Character
Choice 1: (A) workers' compensation
Choice 2: (B) public disability
Choice 3: (C) workers' compensation and public disability
Fill-in (3) - Requested As A Money Amount in Format $$$$$.¢¢
Amount
Fill-in (4) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
Choice 4: his and his family's
Choice 5: her and her family's
Choice 6: your and your family's
WCP005 WORKERS' COMPENSATION/PUBLIC DISABILITY BENEFIT - OFFSET DETERMINED BY AVERAGE CURRENT EARNINGS (ACE) (J37)
(Requested)
Caption: Your Benefits
The pamphlet explains how we reduce (1) Social Security disability benefits. We add the money (2) would receive from us and from (3) . When this total adds up to more than 80 percent of (4) average currently monthly earnings, we reduce (5) Social Security disability benefits. We found that 80 percent of (6) average currently monthly earnings is (7) .
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your
Choice 2: you and your family's
Choice 3: your family's
Choice 4: number holder's name possessive
Choice 5: number holder's name and his family's
Choice 6: number holder's name and her family's
Choice 7: number holder's name possessive plus family's
Fill-in (2) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Choice 4: you and your family's
Choice 5: he and his family's
Choice 6: she and her family's
Fill-in (3) - Requested As A One Position Alpha Character
Choice 1: (A) workers' compensation
Choice 2: (B) public disability benefit payments
Choice 3: (C) workers' compensation and public disability benefit payments
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) - Systems Generated
Choice 1: your
Choice 2: you and your family's
Choice 3: your family's
Choice 4: her
Choice 5: his
Choice 6: her and her family's
Choice 7: his and his family
Choice 8: her family's
Choice 9: his family's
Fill-in (6) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (7) Requested As A Money Amount
Earning amount
WCP008 WORKERS' COMPENSATION OR OTHER DISABILITY CLAIM PENDING AUXILIARY ONLY (J30)
(Requested)
Caption: Information About Other Disability Benefits
If (1) receives workers' compensation and/or public disability payments, we may have to reduce (2) Social Security benefits. At that time, we may also have to recover any money that should not have been paid.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Number holder's name
Fill-in (2) - Systems Generated
Choice 1: Full name possessive
Choice 2: your
WCP009 NUMBERHOLDER APPEALING WORKERS' COMPENSATION DECISION - NUMBERHOLDER ONLY (J38)
(Requested)
Caption: Your Responsibilities
We will not reduce (1) benefit because of (2) payments until (3) a decision on (4) appeal of the claim. Please let us know the decision on the appeal right away. At that time, (5) may have to pay back any Social Security benefits that (6) not due.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Number holder's full name possessive
Choice 2: your
Fill-in (2) - Requested As A One Position Alpha Character
Choice 1: (A) workers' compensation
Choice 2: (B) public disability benefit
Choice 3: (C) workers' compensation and public disability benefit
Fill-in (3) - Systems Generated
Choice 1: you receive
Choice 2: he receives
Choice 3: she receives
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) Systems Generated
Choice 1: you were
Choice 2: he was
Choice 3: she was
WCP010 TOTAL OR PARTIAL WORKERS' COMPENSATION OFFSET NUMBERHOLDER ONLY (J21)
(Requested)
Caption: Your Benefits
We have to take into account (1) (2) of (3) (4) (5) when we figure (6) Social Security benefits. Due to this payment, we are (7) (8) benefits.
NOTE: ENB coding for Fill-in 5, choice 2: MM/YYYY-THROUGH-MM/YYYY. For example, 09/2014-THROUGH-11/2014.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your
Choice 2: Number Holder's Name possessive
Fill-in (2) - Requested As A One Position Alpha Character
Choice 1: (A) workers' compensation payment
Choice 2: (B) public disability payment
Choice 3: (C) workers' compensation and public disability payments
Fill-in (3) - Requested As A Money Amount in Format $$$$$.¢¢ Amount (Workers' Compensation or Public Disability Benefit or combined)
Fill-in (4) - System Generated
Choice 1: beginning
Choice 2: for
Fill-in (5) - Requested As Date In Formats Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (6) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (7) Requested As A One Position Alpha Character
Choice 1: (A) withholding
Choice 2: (B) reducing
Fill-in (8) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
WCP012 OFFSET IMPOSED FIRST MONTH NUMBERHOLDER RECEIVES DISABILITY INSURANCE BENEFITS AND WORKERS' COMPENSATION, OTHER DISABILITY PAYMENT OR BOTH (J19)
(Requested)
Caption: Your Benefits
We are (1) (2) monthly payment beginning (3) . This is the first month when (4) entitled to Social Security disability benefits and (5) payments.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: withholding
Choice 2: reducing
Fill-in (2) - Systems Generated
Choice 1: Beneficiary's Name Possessive
Choice 2: your
Fill-in (3) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY (first month of offset)
Fill-in (4) - Systems Generated
Choice 1: he is
Choice 2: she is
Choice 3: you are
Fill-in (5) - Systems Generated
Choice 1: workers' compensation
Choice 2: public disability
Choice 3: both workers' compensation and public disability
WCP013 CHANGE IN REDUCTION OF WORKERS' COMPENSATION BENEFITS (BECAUSE OF CHANGE IN STATE LAW) (J85)
(Requested
Caption: Your Benefits
Beginning (1) , we are paying (2) a Social Security benefit that is not reduced due to (3) payments. This is because of a change caused by the State law which provides for the reduction of these payments to persons who receive Social Security disability benefits.
Fill-in values:
Fill-in (1) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (2) - Systems Generated
Choice 1: Number holder's name
Choice 2: you
Fill-in (3) - Requested As A One Position Alpha Character
Choice 1: (A) workers' compensation
Choice 2: (B) public disability
Choice 3: (C) workers' compensation and public disability
WCP015 INCREASE IN BENEFITS DUE TO A REDETERMINATION (J31)
(Requested)
Caption: Your Benefits
Based on (1) (2) , every 3 years we check to see if an increase in the national earnings level affects the amount of (3) monthly Social Security benefit. When we checked (4) monthly benefit amount, we found that (5) g due more money.
NOTE : IF W/C is Offset Postponed (O/S), do not request WCP015. This will generate a systems bad.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary's Last Name possessive
Choice 2: your
Fill-in (2) - Systems Generated
Choice 1: workers' compensation
Choice 2: public disability
Choice 3: workers' compensation and public disability
Fill-in (3) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
Fill-in (4) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
Fill-in (5) - Systems Generated
Choice 1: he is
Choice 2: she is
Choice 3: you are
WCP017 INCREASE IN BENEFITS AFTER WORKERS' COMPENSATION - OFFSET FIRST IMPOSED (J32)
(Requested)
Caption: Your Benefits
(1) benefits were increased beginning (2) (3) (4) (5) not reduced because of (6) payments.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary name possessive
Choice 2: Number holder's first name possessive
Choice 3: Beneficiary given and last name possessive
Choice 4: Your
Choice 5: Beneficiary given possessive
Fill-in (2) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY or MM/CCYY through MM/CCYY or MM/CCYY and MM/CCYY
Fill-in (3) - Systems Generated
Choice 1: null
Choice 2: null
Fill-in (4) - Systems Generated
Choice 1: null
Choice 2: null
Fill-in (5) - Systems Generated
Choice 1: This increase was
Choice 2: These increases were
Fill-in (6) - Systems Generated
Choice 1: workers' compensation
Choice 2: public disability
Choice 3: workers compensation and public disability
WCP018 REMOVAL OF OFFSET WORKERS' COMPENSATION OR OTHER DISABILITY PAYMENTS TERMINATED (J27)
(Requested)
Caption: Your Benefits
We do not reduce benefits once (1) payments have stopped. Therefore, we are paying benefits at the full rate beginning (2) . Please let us know right away if (3) workers' compensation and/or other public disability payments again.
Fill-in values:
Fill-in (1) - Requested As A One Position Alpha Character
Choice 1: (A) workers' compensation
Choice 2: (B) public disability
Choice 3: (C) workers' compensation and public disability
Fill-in (2) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (3) - Systems Generated
Choice 1: Number holder's name receives
Choice 2: you receive
WCP019 REMOVAL OF OFFSET NUMBERHOLDER AGE 62 OR 65 (J28) – (BORN 12/19/1950 OR EARLIER)
(Requested)
Caption: Your Benefits
Beginning (1) , we are not reducing (2) benefit because of (3) payments. We do not reduce benefits for months when the disabled worker is age (4) or over.
Fill-in values:
Fill-in (1) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY number holder attains age 62 or 65
Fill-in (2) - Systems Generated
Choice 1: Number holder's name possessive
Choice 2: Number holder's first name possessive (NOT USED BY MADCAP)
Choice 3: Beneficiary given and last name possessive
Choice 4: Your
Fill-in (3) - Requested As A One Position Alpha Character
Choice 1: (A) workers' compensation
Choice 2: (B) public disability
Choice 3: (C) workers' compensation and public disability
Fill-in (4) - Requested As A One Position Alpha Character
Choice 1: (A) 62
Choice 2: (B) 65
WCP021 POSSIBLE EXCLUDABLE EXPENSES WORKERS' COMPENSATION (J33)
(Requested)
Caption: Information About Other Disability Benefits
If (1) had expenses related to (2) claim for (3) payments, please give us proof that (4) paid these expenses. These expenses may include medical, legal, or other related expenses. We may be able to deduct some of these expenses when we figure (5) Social Security benefits.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Number holder's name
Choice 2: you
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) workers' compensation
Choice 2: (B) workers' compensation and public disability benefit
Choice 3: (C) public disability benefit
Fill-in (4) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (5) - Systems Generated
Choice 1: your and your family's
Choice 2: number holder's name possessive
Choice 3: your family's
Choice 4: your
Choice 5: Number holder's name possessive + and his family's
Choice 6: Number holder's name possessive + and her family's
Choice 7: Number holder's name possessive + family's
WCP026 BENEFICIARY NO LONGER ENTITLED TO BENEFITS (J80)
(Requested)
Caption: Your Benefits
We changed (1) monthly benefit to (2) beginning (3) because benefits to another entitled person stopped. When we figured (4) benefit, we had to take into account (5) (6) payments.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary's name possessive
Choice 2: your
Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Amount
Fill-in (3) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (4) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
Fill-in (5) - Systems Generated
Choice 1: NH Name possessive
Fill-in (6) - Systems Generated
Choice 1: workers' compensation
Choice 2: public disability
Choice 3: workers' compensation and public disability
WCP028 BENEFITS OFFSET NUMBERHOLDER MAY FILE FOR REDUCED RIB (J20) – (BORN 12/19/1950 OR EARLIER)
WCP028
(Requested)
Caption: Things To Remember
We may continue to reduce or withhold (1) disability benefits until (2) age 65. We must take this action because of (3) (4) payments. (5) payments do not affect retirement benefits. (6) may be eligible for retirement benefits at age 62. To apply, please get in touch with us three months before (7) age 62.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your
Choice 2: your and your family's
Choice 3: Number holder's name possessive
Choice 4: your family's
Choice 5: Number holder's name possessive and his family's
Choice 6: Number holder's name possessive and her family's
Choice 7: Beneficiary full name possessive plus family's
Fill-in (2) - Systems Generated
Choice 1: you reach
Choice 2: he reaches
Choice 3: she reaches
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) workers' compensation
Choice 2: (B) workers' compensation and public disability benefit
Choice 3: (C) public disability benefit
Fill-in (5) - Requested As A One Position Alpha Character
Choice 1: (A) Workers' compensation
Choice 2: (B) Workers' compensation and public disability benefit
Choice 3: (C) Public disability benefit
Fill-in (6) - Systems Generated
Choice 1: You
Choice 2: He
Choice 3: She
Fill-in (7) - Systems Generated
Choice 1: you reach
Choice 2: he reaches
Choice 3: she reaches
WCP029 WORKERS' COMPENSATION OR OTHER DISABILITY CLAIM PENDING - NUMBERHOLDER ONLY (J29)
(Requested)
Caption: Your Responsibilities
If (1) workers' compensation and/or public disability benefit payments, we may have to reduce (2) Social Security benefits.
At that time, (3) may also have to pay back any Social Security benefits that (4) not due. Please let us know the decision on the claim right way.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Number holder's full name receives
Choice 2: you receive
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (4) - Systems Generated
Choice 1: you were
Choice 2: he was
Choice 3: she was
WCP032 ALL LETTERS INVOLVING RECEIPT OF WORKERS' COMPENSATION OR OTHER DISABILITY PAYMENTS NUMBERHOLDER (J43)
(Systems Generated)
Caption: Your Responsibilities
Please let us know right away about any:
Changes in (1) workers' compensation or public disability benefit payments
Lump-sum award(s) (2)
Other payments (3) that increase or decrease (4) workers' compensation or public disability benefit payments
Fill-in values:
Fill-in (1) Systems Generated
Choice 1: Beneficiary full name possessive
Choice 2: your
Fill-in (2) Systems Generate
Choice 1: you receive
Choice 2: he receives
Choice 3: she receives
Fill-in (3) Systems Generated
Choice 1: you receive
Choice 2: he receives
Choice 3: she receives
Fill-in (4) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
WCP048 TOTAL OR PARTIAL OFFSET - AUXILIARY ONLY (J22)
(Requested)
Caption: Your Benefits
We have to take into account (1) (2) payments when we figure (3) Social Security benefits. Because of these payments, we are (4) the benefits (5) due (6) (7) .
NOTE: If the Technician input a date for Fill-in 7 the word “through” will be generated. If the technician selects “A” for null then the notice will end after Fill-in 6.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Name of Numberholder (possessive)
Choice 2: your
Fill-in (2) - Systems Generated
Choice 1: workers' compensation
Choice 2: public disability
Choice 3: workers' compensation and public disability
Fill-in (3) - Systems Generated
Choice 1: your
Choice 2: Auxiliary name possessive
Fill-in (4) - Requested As A One Position Alpha Character
Choice 1: (A) withholding
Choice 2: (B) reducing
Fill-in (5) - Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (6) - Requested As A Date In Format Shown Below
MM/CCYY
Fill-in (7) - Requested As A Date In Format Shown Below
Choice 1: Null
Choice 2: Through
WCP049 AMOUNT OF BENEFIT RECEIVED AFTER OFFSET (J23)
(Requested)
Caption: Your Benefits
Benefit Amount Beginning Date Reason
(1) (2) (3) g
NOTE : This Universal Text Identifier is flexible, to allow multiple repetitions of the three fill-ins. This allows it to be used once, and provide as many benefit amount, dates and reasons as are needed to explain the action, or twice with the benefit amount, date and reason. When there is more than one row of data to display under the headers in the chart, WCP059 is automatically generated. An example of how to input this in the ENB screen is:
C*WCP049,500.00,09/2010,A,530.00,01/2011,C. (This method invokes WCP059, beginning with the second entry.) OR
WCP049,500.00,05/2013,I*WCP049,530.00,06/2013,A.
Fill-in values:
Fill-in (1) - Requested As A Money Amount In Format $$$$$.¢¢
Benefit Amount
Fill-in (2) - Requested As A Date In Format Shown Below
MM/CCYY
Fill-in (3) - Requested As An One Position Alpha Character
Choice 1 (A): Entitlement began
Choice 2 (B): Cost of living adjustment
Choice 3 (C): Credit for additional earnings
Choice 4 (D): Your own benefit increased
Choice 5 (E): His own benefit increased
Choice 6 (F): Her own benefit increased
Choice 7 (G): Because we stopped paying another person on this record
Choice 8 (H): Because we started paying another person on this record
Choice 9 (I): Because of the receipt of worker's compensation payments
Choice 10 (J): Because of the receipt of public disability payments
Choice 11 (K): Because of the receipt of worker's compensation and public disability payments
WCP050 SUBSEQUENT ADJUSTMENT TO PRORATION PERIOD BASED ON NEW EVIDENCE (J75)
(Requested)
Caption: Your Benefits
We told (1) earlier that we would pay (2) full Social Security benefits beginning (3) . Because of new facts we have received, we will now pay (4) full benefits beginning (5) .
Fill-in values:
Fill-in (1) Systems Generated
Choice 1: you
Choice 2: Beneficiary's name
Fill-in (2) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (3) - Requested As A Date In Format Shown Below
MM/CCYY when Numberholder was informed full Disability Insurance Benefit was payable
Fill-in (4) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (5) - Requested As A Date In Format Shown Below
MM/CCYY when full Disability Insurance Benefit actually payable
WCP051 CHANGE IN AMOUNT OF THE AVERAGE CURRENT EARNINGS (ACE) (J76)
(Requested)
Caption: Your Benefits
We told (1) earlier that we might change the amount of (2) benefits when we got more facts about the money (3) earned while (4) working. Using the new facts about (5) earnings, we found that 80 percent of (6) average current earnings was (7) . For this reason, we are increasing (8) Social Security benefits beginning (9) .
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: he
Choice 3: she
Fill-in (4) - Systems Generated
Choice 1: you were
Choice 2: he was
Choice 3: she was
Fill-in (5) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (6) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (7) - Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Average Current Earnings
Fill-in (8) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (9) - Requested As A Date In Format Shown Below
MM/CCYY
WCP052 RESUMPTION OF OFFSET - NUMBERHOLDER ONLY (J77
(Requested)
Caption: Your Benefits
Beginning (1) , we paid (2) full Social Security checks because (3) (4) payments stopped. Now that (5) these payments of (6) each week, we reduced (7) Social Security benefits beginning (8) . (9) new benefit is shown above.
Fill-in values:
Fill-in (1) - Requested As A Date In Format Shown Below
MM/CCYY
Fill-in (2) - Systems Generated
Choice 1: you
Choice 2: beneficiary's name
Fill-in (3) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (4) - Systems Generated
Choice 1: Worker's compensation
Choice 2: Public disability
Choice 3: Worker's compensation and Public disability
Fill-in (5) - Systems Generated
Choice 1: you again receive
Choice 2: he again receives
Choice 3: she again receives
Fill-in (6) - Requested As A Money Amount In Format $$$$$.¢¢
Amount of weekly Workers' Compensation
Fill-in (7) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (8) - Requested As A Date In Format Shown Below
MM/CCYY
Fill-in (9) - Systems Generated
Choice 1: Your
Choice 2: His
Choice 3: Her
WCP053 RESUMPTION OF OFFSET - AUXILIARIES ONLY (J78)
(Requested)
Caption: Your Benefits
Beginning (1) , we paid (2) full Social Security checks because (3) (4) payments stopped. Now that these payments have started again, we reduced (5) Social Security benefits beginning (6) . (7) new benefit rate is shown above.
Fill-in values:
Fill-in (1) - Requested As A Date In Format Shown Below
MM/CCYY
Fill-in (2) Systems Generated
Choice 1: you
Choice 2: Beneficiary's name
Fill-in (3) Systems Generated
Choice 1: Numberholder's full name (possessive)
Fill-in (4) Systems Generated
Choice 1: workers' compensation
Choice 2: public disability
Choice 3: workers' compensation and public disability
Fill-in (5) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (6) Requested As A Date In Format Shown Below
MM/CCYY offset resumed
Fill-in (7) - Systems Generated
Choice 1: Your
Choice 2: His
Choice 3: Her
WCP054 VERIFIED RATE OF WORKERS' COMPENSATION, OTHER DISABILITY PAYMENT OR BOTH (J83)
(Requested)
Caption: Your Benefits
We have learned that (1) weekly (2) payment is (3) rather than (4) , as we had previously been told. Therefore, we have changed (5) Social Security benefits beginning (6) g .
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your
Choice 2: Beneficiary's name possessive
Fill-in (2) - Systems Generated
Choice 1: workers' compensation
Choice 2: public disability
Choice 3: workers' compensation and public disability
Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢
Amount of Workers' Compensation received
Fill-in (4) - Requested As A Money Amount In Format $$$$$.¢¢
Amount of Workers' Compensation reported
Fill-in (5) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (6) - Requested As A Date In Format Shown Below
MM/CCYY (date of adjustment)
WCP055 THIRD PARTY INVOLVEMENT (J84)
(Requested)
Caption: Your Benefits
We learned that (1) received a third-party settlement. Since this was not a workers' compensation payment, we will not have to reduce (2) benefit. We also learned that the workers' compensation (3) had already received was to be repaid because of the settlement. Since we do not have to reduce (4) benefits because of the workers' compensation, we will pay (5) the money we have withheld.
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: 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: him
Choice 3: her
WCP057 REMOVAL OF OFFSET - LUMP-SUM PRORATION ENDED (J91)
(Requested)
Caption: Your Benefits
Beginning (1) , we can pay (2) benefits at the full rate. This is because we are no longer considering the (3) lump-sum award when we figure the benefit amount.
Please let us know right away if (4) workers' compensation and/or other public disability payments.
Fill-in values:
Fill-in (1) - Requested As A Date In Format Shown Below
Date offset no longer applies
Fill-in (2) - Systems Generated
Choice 1: you
Choice 2: Beneficiary Name
Fill-in (3) - Requested As A One Position Alpha Character
Choice 1:A workers' compensation
Choice 2:B public disability
Choice 3:C workers' compensation and public disability
Fill-in (4) - Systems Generated
Choice 1: you again receive
Choice 2: he again receives
Choice 3: she again receives
WCP058 CHANGE IN WORKERS' COMPENSATION RATE, OTHER DISABILITY PAYMENT OR BOTH AND OFFSET ADJUSTED NUMBERHOLDER ONLY (J81)
(Requested)
Caption: Your Benefits
We have learned that (1) weekly (2) payment was changed to (3) . For this reason, we have changed (4) Social Security benefits beginning (5) .
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your
Choice 2: Beneficiary's name possessive
Fill-in (2) - Requested As A One Position Alpha Character
Choice 1: (A) workers' compensation
Choice 2: (B) public disability
Choice 3: (C) workers' compensation and public disability
Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢
Amount
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: her
Choice 3: his
Fill-in (5) - Requested As A Date In Format Shown Below
MM/CCYY
WCP059 AMOUNT OF BENEFIT RECEIVED AFTER OFFSET (J23 DETAIL LINE)
(Systems generated)
Caption: Your Benefits
(1) (2) (3) g
NOTE : This Universal Text Identifier is automatically generated whenever WCP049 is requested and there is more than one row of data to display under the headers in the chart.
Fill-in values:
Fill-in (1) - Systems Generated As A Money Amount In Format $$$$$.¢¢
Benefit Amount
Fill-in (2) - Systems Generated As A Date In Format Shown Below
MM/CCYY
Fill-in (3) - Systems Generated As An One Position Alpha Character
Choice 1 (A): Entitlement began
Choice 2 (B): Cost of living adjustment
Choice 3 (C): Credit for additional earnings
Choice 4 (D): Your own benefit increased
Choice 5 (E): His own benefit increased
Choice 6 (F): Her own benefit increased
Choice 7 (G): Because we stopped paying another person on this record
Choice 8 (H): Because we started paying another person on this record
Choice 9 (I): Because of the receipt of worker's compensation payments
Choice 10 (J): Because of the receipt of public disability payments
Choice 11 (K): Because of the receipt of worker's compensation and public disability payments
WCP060 WORKERS' COMPENSATION/PUBLIC DISABILITY BENEFIT - REMOVAL OF OFFSET – NUMBERHOLDER ATTAINS FULL RETIREMENT AGE (FRA) (BORN 12/20/1950 OR LATER)
(Requested)
Caption: Your Benefits
Starting (1) , we will stop reducing (2) Social Security disability benefits because of (3) (4) payments. We stop reducing disability benefits when (5) full retirement age.
Fill-in values:
Fill-in (1) - Systems Generated As A Date In Format Shown Below
Choice 1: Show date of Full Retirement Age attainment in the format Month CCYY
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: Beneficiary's name (possessive)
Fill-in (3) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (4) - Requested As An One Position Alpha Character
Choice 1: (A) workers' compensation
Choice 2: (B) public disability benefit
Choice 3: (C) workers' compensation and public disability benefit
Fill-in (5) - Systems Generated
Choice 1: you reach
Choice 2: he reaches
Choice 3: she reaches
WCP061 WORKERS' COMPENSATION/PUBLIC DISABILITY BENEFIT - OFFSET TO FRA - NUMBERHOLDER MAY FILE FOR REDUCED RETIREMENT INSURANCE BENEFIT (BORN 12/20/1950 OR LATER)
(Requested)
Caption: Things To Remember
We will continue to reduce or withhold (1) disability benefits until (2) full retirement age in (3) . We must take this action because of (4) (5) payments.
(6) (7) payments do not affect retirement benefits. (8) may be eligible for reduced retirement benefits at age 62. If (9) to apply for retirement benefits, please contact us three months before (10) age 62.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your
Choice 2: Number holder's name possessive
Choice 3: your and your family's
Choice 4: your family's
Choice 5: Number holder's name possessive and his family's
Choice 6: Number holder's name possessive and her family's
Choice 7: Beneficiary full name possessive plus family's
Fill-in (2) - Systems Generated
Choice 1: you reach
Choice 2: he reaches
Choice 3: she reaches
Fill-in (3) - Systems Generated As A Date In Format Shown Below
Choice 1: Show date of Full Retirement Age attainment in the format Month CCYY
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) - Requested As An One Position Alpha Character
Choice 1: (A) workers' compensation
Choice 2: (B) public disability
Choice 3: (C) workers' compensation and public disability
Fill-in (6) - Systems Generated
Choice 1: Your
Choice 2: His
Choice 3: Her
Fill-in (7) - Requested As An One Position Alpha Character
Choice 1: (A) workers' compensation
Choice 2: (B) public disability
Choice 3: (C) workers' compensation and public disability
Fill-in (8) - Systems Generated
Choice 1: You
Choice 2: He
Choice 3: She
Fill-in (9) - Systems Generated
Choice 1: you decide
Choice 2: he decides
Choice 3: she decides
Fill-in (10) - Systems Generated
Choice 1: you reach
Choice 2: he reaches
Choice 3: she reaches
WCPR02 NUMBERHOLDER APPEALING WORKERS' COMPENSATION DECISION - AUXILIARY ONLY (J39)
(Requested)
Caption: Information About Other Disability Benefits
We will not reduce (1) because of (2) (3) payments until a decision is made on the appeal of the claim. At that time, we may collect any money that should not have been paid.
Fill-in values:
Fill-in (1) Systems Generated
Choice 1: Beneficiary's Name, possessive
Choice 2: your
Fill-in (2) Systems Generated
Choice 1: number holder's name possessive
Fill-in (3) Systems Generated
Choice 1: workers' compensation
Choice 2: public disability
Choice 3: workers' compensation and public disability
WCPR06 AMOUNT OF OFFSET BASED ON ESTIMATE FOR ONE OR MORE YEARS - HIGH 1 (J49)
(Requested)
Caption: Information About Other Disability Benefits
When we figured how much to reduce (1) benefits, we used an estimate for part of (2) earnings before (3) became disabled. According to our records, the year in which (4) earned the most money between (5) and (6) was (7) . We estimated (8) earnings for that year to be (9) . If (10) (11) that this amount is wrong, please let us know. (12) will also need to give us any facts (13) to show that the amount is wrong.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your and your family's
Choice 2: number holder's name possessive
Choice 3: your family's
Choice 4: number holder's name and his family
Choice 5: number holder's name and her family
Choice 6: number holder's name possessive plus family's
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: her
Choice 3: his
Fill-in (3) - Systems Generated
Choice 1: you
Choice 2: she
Choice 3: he
Fill-in (4) - Systems Generated
Choice 1: you
Choice 2: she
Choice 3: he
Fill-in (5) - Systems Generated
Choice 1: date of onset minus 5 years
Fill-in (6) - Systems Generated
Choice 1: date of onset in year format
Fill-in (7) - Requested As A Date In Format CCYY
Choice 1: year of highest regular earnings
Fill-in (8) - Systems Generated
Choice 1: your
Choice 2: her
Choice 3: his
Fill-in (9) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: highest regular earnings
Fill-in (10) - Systems Generated
Choice 1: you
Choice 2: she
Choice 3: he
Fill-in (11) - Systems Generated
Choice 1: think
Choice 2: thinks
Fill-in (12) - Systems Generated
Choice 1: You
Choice 2: She
Choice 3: He
Fill-in (13) - Systems Generated
Choice 1: you have
Choice 2: she has
Choice 3: he has
WCPR07 AMOUNT OF OFFSET BASED ON ESTIMATE FOR ONE OR MORE YEARS - HIGH 5 (J25)
(Requested)
Caption: Information About Other Disability Benefits
When we figured how much to reduce (1) benefits, we used an estimate for part of (2) earnings before (3) became disabled. According to our records, the 5 years in which (4) earned the most money were (5) to (6) . We estimated that (7) earned (8) during this period. If (9) that this amount is wrong, please let us know. (10) will also need to give us any facts (11) g to show that the amount is wrong.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your and your family's
Choice 2: number holder's name possessive
Choice 3: your familys
Choice 4: your
Choice 5: number holder's name and his family
Choice 6: number holder's name and her family
Choice 7: number holder's name possessive plus family's
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: her
Choice 3: his
Fill-in (3) - Systems Generated
Choice 1: you
Choice 2: she
Choice 3: he
Fill-in (4) - Systems Generated
Choice 1: you
Choice 2: she
Choice 3: he
Fill-in (5) - Requested As A Date In Format Shown Below
Choice 1: CCYY
Fill-in (6) - Requested As A Date In Format Shown Below
Choice 1: CCYY
Fill-in (7) - Systems Generated
Choice 1: you
Choice 2: she
Choice 3: he
Fill-in (8) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: money amount
Fill-in (9) - Systems Generated
Choice 1: you think
Choice 2: number holder's name thinks
Fill-in (10) - Systems Generated
Choice 1: You
Choice 2: She
Choice 3: He
Fill-in (11) - Systems Generated
Choice 1: has
Choice 2: have
WCPR09 INTERIM NOTICE PENDING AVERAGE CURRENT EARNINGS DETERMINATION (J57)
(Requested)
Caption: Information About Other Disability Benefits
We may have to change the amount of (1) benefits when we receive proof of the amount of (2) average current earnings. We use these earnings to figure how much to deduct from (3) benefits.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Full name possessive
Choice 2: your
Fill-in (2) - Systems Generated
Choice 1: number holder's name
Choice 2: your
Choice 3: her
Choice 4: his
Fill-in (3) - Systems Generated
Choice 1: Full name
Choice 2: your
Choice 3: her
Choice 4: his
WCPR13 OFFSET IMPOSED AFTER DATE OF NOTICE (J26)
(Requested)
Caption: Your Benefits
We are reducing (1) benefits beginning (2) g because of workers' compensation payments. We must reduce benefits beginning with the month after the month in which we were told about these payments.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Number holder's name possessive
Choice 2: Number holder's first name possessive
Choice 3: beneficiary given and last name possessive
Choice 4: your
Fill-in (2) - Systems Generated
Choice 1: first month and year of offset
WCPR15 CHANGE IN WORKERS' COMPENSATION RATE, OTHER DISABILITY PAYMENT OR BOTH AND OFFSET ADJUSTED - AUXILIARY ONLY (J82)
(Requested)
Caption: Your Benefits
We are (1) (2) benefits beginning (3) , when (4) (5) payments changed from (6) to (7) .
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: withholding
Choice 2: reducing
Fill-in (2) - Systems Generated
Choice 1: Number holder's full name possessive
Choice 2: Number holder's first name possessive
Choice 3: your
Fill-in (3) - Requested As A Date In Format Shown Below
MM/CCYY
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: her
Choice 3: his
Fill-in (5) - Systems Generated
Choice 1: workers' compensation
Choice 2: public disability
Choice 3: workers' compensation and public disability
Fill-in (6) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: prior money amount
Fill-in (7) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: current money amount
WCPR20 OFFSET BASED ON LUMP SUM ENDING DATE OF PRORATION (J36)
(Requested)
Caption: Your Benefits
We changed (1) monthly benefit because (2) received a (3) lump-sum award. We treat a lump-sum award as if it were paid on a weekly basis. We (4) a full Social Security benefit to (5) beginning (6) .
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Number holder's name possessive
Choice 2: beneficiary given name possessive
Choice 3: beneficiary given and last name possessive
Choice 4: your
Fill-in (2) - Systems Generated
Choice 1: you
Choice 2: she
Choice 3: he
Fill-in (3) - Systems Generated
Choice 1: workers' compensation
Choice 2: public disability
Choice 3: workers' compensation and public disability
Fill-in (4) - Systems Generated
Choice 1: will pay
Choice 2: will start paying
Fill-in (5) - Systems Generated
Choice 1: you
Choice 2: her
Choice 3: him
Fill-in (6) - Systems Generated
Choice 1: Month and Year
WCPR22 WORKERS' COMPENSATION EXCLUDABLE AMOUNTS DEDUCTED (J42)
(Requested)
Caption: Information About Other Disability Benefits
When we figure how much to reduce (1) benefits, we do not count certain medical, legal, or other expenses which were paid out of (2) (3) payments. We excluded (4) when we figured (5) benefits.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your and your family's
Choice 2: number holder's name possessive
Choice 3: your family's
Choice 4: your
Choice 5: number holder's name and his family
Choice 6: number holder's name and her family
Choice 7: number holder's name possessive plus family's
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: her
Choice 3: his
Fill-in (3) - Systems Generated
Choice 1: workers' compensation
Choice 2: public disability
Choice 3: workers' compensation and public disability
Fill-in (4) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: actual amount of excludable expenses
Fill-in (5) - Systems Generated
Choice 1: your and your family's
Choice 2: number holder's name possessive
Choice 3: your family's
Choice 4: your
Choice 5: number holder's name and his family
Choice 6: number holder's name and her family
Choice 7: number holder's name possessive plus family's
WCPR23 OFFSET BASED ON LUMP SUM PRORATION METHOD A (J45)
(Requested)
Caption: Your Benefits
(1) (2) received a lump-sum award of (3) to settle (4) (5) claim. A lump-sum award affects Social Security benefits in the same way that periodic payments do. We treat a lump-sum award as if it were paid on a weekly basis.
When we figured how much to reduce (6) benefits, we treated the lump sum as if (7) had been paid (8) each week. We excluded (9) for legal expenses, and (10) for medical expenses. Based on these facts, we can pay (11) full benefits for (12) through (13) . We will reduce (14) benefits beginning (15) . We will again pay full benefits beginning (16) .
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: You
Choice 2: Number holder's full name
Fill-in (2) - Systems Generated
Choice 1: have
Choice 2: has
Fill-in (3) - Systems Generated
Choice 1: money amount
Fill-in (4) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
Fill-in (5) - Systems Generated
Choice 1: workers' compensation
Choice 2: public disability
Choice 3: workers' compensation and public disability
Fill-in (6) - Systems Generated
Choice 1: your
Choice 2: your and your family's
Choice 3: your family's
Choice 4: Number Holder's name possessive
Choice 5: number holder's name and his family
Choice 6: number holder's name and her family
Choice 7: number holder's name possessive plus family's
Fill-in (7) - Systems Generated
Choice 1: you
Choice 2: Number Holder's full name
Fill-in (8) - Systems Generated
Choice 1: money amount
Fill-in (9) - Systems Generated
Choice 1: attorney fee amount
Fill-in (10) - Systems Generated
Choice 1: amount of medical expenses
Fill-in (11) - Systems Generated
Choice 1: you
Choice 2: you and your family
Choice 3: your family
Choice 4: him
Choice 5: her
Choice 6: his family
Choice 7: her family
Choice 8: him and his family
Choice 9: her and her family
Fill-in (12) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (13) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (14) - Systems Generated
Choice 1: youy
Choice 2: youy and your family
Choice 3: your family
Choice 4: his
Choice 5: her
Choice 6: his family's
Choice 7: her family's
Choice 8: his and his family's
Choice 9: her and her family's
Fill-in (15) - Requested As A Date In Format MM/CCYY
Choice 1: Date (beginning of offset)
Fill-in (16) - Requested As A Date In Format MM/CCYY
Choice 1: Date (end of offset)
WCPR24 OFFSET BASED ON LUMP SUM PRORATION METHOD B (J46)
(Requested)
Caption: Your Benefits
(1) (2) received a lump-sum award of (3) to settle (4) (5) claim. A lump-sum award affects Social Security benefits in the same way that periodic payments do. We treat a lump-sum award as if it were paid on a weekly basis.
When we figured how much to reduce (6) benefits, we treated the lump sum as if (7) had been paid (8) each week. We excluded (9) for legal expenses, medical and other expenses. For this reason, we lowered the weekly rate from (10) to (11) . This means that we will send (12) (13) benefits beginning (14) . (15) (16)
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Number holder's full name
Choice 2: You
Fill-in (2) - Systems Generated
Choice 1: have
Choice 2: has
Fill-in (3) - Systems Generated
Choice 1: lump sum gross amount
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Choice 4: their
Fill-in (5) - Systems Generated
Choice 1: workers' compensation
Choice 2: public disability
Choice 3: workers' compensation and public disability
Fill-in (6) - Systems Generated
Choice 1: your
Choice 2: your and your family's
Choice 3: your family's
Choice 4: number holder's name possessive
Fill-in (7) - Systems Generated
Choice 1: Number holder's full name
Choice 2: you
Fill-in (8) - Systems Generated
Choice 1: money amount
Fill-in (9) - Systems Generated
Choice 1: total amount of excludable expenses
Fill-in (10) - Systems Generated
Choice 1: money amount
Fill-in (11) - Systems Generated
Choice 1: money amount
Fill-in (12) - Systems Generated
Choice 1: you
Choice 2: you and your family
Choice 3: your family
Choice 4: him and his family
Choice 5: her and her family
Choice 6: her family
Choice 7: his family
Choice 8: him
Choice 9: her
Fill-in (13) - Requested As A One Position Alpha Character
Choice 1: (A) additional
Choice 2: (B) partial
Choice 3: (C) full
Fill-in (14) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (15) - Systems Generated
Choice 1: We will pay full benefits beginning
Choice 2: null
Fill-in (16) - Systems Generated
Choice 1: ending date plus 1 month
Choice 2: null
WCPR25 OFFSET BASED ON LUMP SUM PRORATION METHOD C (J47)
(Requested)
Caption: Your Benefits
(1) (2) received a lump-sum award of (3) to settle (4) (5) claim. A lump-sum award affects Social Security benefits in the same way that periodic payments do. We treat a lump-sum award as if it were paid on a weekly basis.
When we figured how much to reduce (6) benefits, we excluded (7) for legal, medical and other expenses. We treated the rest of the lump sum, (8) , as if (9) had been paid (10) per week. We will pay full benefits beginning (11) .
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Number holder's full name
Choice 2: You
Fill-in (2) - Systems Generated
Choice 1: have
Choice 2: has
Fill-in (3) - Systems Generated
Choice 1: lump sum gross amount
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: her
Choice 3: his
Fill-in (5) - Systems Generated
Choice 1: workers' compensation
Choice 2: public disability
Choice 3: workers' compensation and public disability
Fill-in (6) - Systems Generated
Choice 1: your
Choice 2: your and your family
Choice 3: your family's
Choice 4: number holder's name possessive
Choice 5: number holder's name plus his family's
Choice 6: number holder's name plus her family's
Choice 7: number holder's name possessive plus family's
Fill-in (7) - Systems Generated
Choice 1: sum of attorney and medical expenses
Fill-in (8) - Systems Generated
Choice 1: lump sum which remains
Fill-in (9) - Systems Generated
Choice 1: you
Choice 2: she
Choice 3: he
Fill-in (10) - Systems Generated
Choice 1: money amount
Fill-in (11) - Systems Generated
Choice 1: lump sum prorated ending date plus one month (month and year full benefits payable)
WCPR27 OFFSET BASED ON UNVERIFIED ALLEGATION (J41)
(Requested)
Caption: Information About Other Disability Benefits
We may have to change the amount of (1) benefits when we receive proof of the amount of (2) (3) payments.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Full name possessive
Choice 2: your
Fill-in (2) - Systems Generated
Choice 1: Name possessive
Fill-in (3) - Systems Generated
Choice 1: workers' compensation
Choice 2: public disability
Choice 3: workers' compensation and public disability
WCPR31 NUMBERHOLDER APPEALING WORKERS' COMPENSATION DECISION - NUMBERHOLDER AND AUXILIARY (J40)
(Requested)
Caption: Your Responsibilities
We will not reduce (1) benefit, or the benefits of (2) family, because of (3) payments until a decision is made on the appeal of (4) claim. Please let us know when a final decision is made. At that time, we may collect any money that should not have been paid.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Number holder full name possessive
Choice 2: your
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: her
Choice 3: his
Fill-in (3) - Systems Generated
Choice 1: workers' compensation
Choice 2: public disability
Choice 3: workers' compensation and public disability
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: her
Choice 3: his