NL: Notices, Letters and Paragraphs
BASIC (05-11)
XRP001 PROVISIONAL PAYMENT ALLOWANCE (P01)
(Requested)
Caption: None
We are writing to tell you that (1) will receive provisional Social Security disability benefits based on (2) request for reinstatement.
Under the Ticket to Work and Work Incentives Improvement Act of 1999, we can pay (3) up to 6 months of provisional benefits while (4) request for reinstatement is being decided. (5) will receive another letter when we make our decision on (6) request.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you
Choice 2: beneficiary full 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: beneficiary full name
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
Choice 3: beneficiary full name
Fill-in (6) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
XRP002 PROVISIONAL PAYMENTS BASED ON MONTHLY AMOUNT (P02)
(Requested)
Caption: What We Will Pay
The amount of (1) monthly provisional benefit is based on the amount of (2) last monthly Social Security benefit plus cost of living increases.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
XRP003 6 MONTHS PROVISIONAL PAYMENTS PAID IN SINGLE PAYMENT (P03)
(Requested)
Caption: What We Will Pay
Because this is (1) payment for 6 months of provisional benefits, (2) will not receive any additional provisional benefits.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (2) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
XRP004 WHEN PROVISIONAL PAYMENTS WILL END (P04)
(Requested)
Caption: When provisional benefits end
Under the law, (1) provisional benefits will end with the earliest of:
The month we make a determination about (2) request for reinstatement; or
The month (3) substantial gainful activity; or
The month before (4) full retirement age; or
The fifth month following the month (5) made (6) request. This means that if none of the other conditions apply, then (7) provisional benefits will end (8) .
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3) - Systems Generated
Choice 1: you return to work and perform
Choice 2: he returns to work and performs
Choice 3: she returns to work and performs
Fill-in (4) - Systems Generated
Choice 1: you reach
Choice 2: he reaches
Choice 3: she reaches
Fill-in (5) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (6) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
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
Choice 1: Month CCYY (the 5th month after the date recorded on the PERI screen of the Title II Post entitlement Online System.)
XRP005 EXPLANATION THAT PROVISIONAL BENEFITS MAY NOT HAVE TO BE REPAID (P05)
(Requested)
Caption: Other information
If we deny (1) request for reinstatement, (2) generally will not have to repay the provisional benefits (3) received unless we determine that (4) knew or should have known that (5) did not meet the reinstatement requirements.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (2) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (3) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (4) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (5) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
XRP006 TERMINATION OF PROVISIONAL BENEFITS - 6 MONTHS PROVISIONAL BENEFIT PAID (P15)
(Requested)
Caption: Why Your Provisional Benefits Ended
We are writing to tell you that (1) no longer can receive provisional Social Security disability benefits based on (2) request for reinstatement. The last month for which (3) can receive provisional benefits is (4) .
Under the law, we can pay (5) up to 6 months of provisional benefits while (6) request for reinstatement is being decided. Our records show that we have paid these benefits for 6 months. (7) will receive another letter when we make our decision on (8) request.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you
Choice 2: beneficiary's full 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: beneficiary's full name
Fill-in (4) - Requested As A Date In Format Shown Below
Choice 1: Month CCYY
Fill-in (5) - Systems Generated
Choice 1: you
Choice 2: beneficiary's full name
Fill-in (6) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (7) - Systems Generated
Choice 1: You
Choice 2: beneficiary's full name
Fill-in (8) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
XRP007 MEDICARE COVERAGE TERMINATED - PROVISIONAL BENEFITS ENDED (P13)
(Requested)
Caption: Information About Medicare
As we told you in our earlier notice (1) would have Medicare (2) insurance coverage while (3) received provisional benefits. Because (4) provisional benefits have ended, (5) Medicare (6) insurance coverage will end at the same time.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you
Choice 2: beneficiary's full name
Fill-in (2) - Requested As A One Position Alpha Character
Choice A: hospital
Choice B: hospital and medical
Fill-in (3) - Systems Generated
Choice 1: you
Choice 2: beneficiary's full name
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (6) - Requested As A One Position Alpha Character
Choice 1: (A) hospital
Choice 2: (B) hospital and medical
XRP008 TERMINATION OF PROVISIONAL BENEFITS - BENEFICIARY ATTAINED FULL RETIREMENT AGE (FRA) (P14)
(Requested)
Caption: None
We are writing to tell you that (1) no longer can receive provisional Social Security disability benefits based on (2) request for reinstatement. (3) will receive another letter when we make our decision on (4) request.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you
Choice 2: beneficiary's full 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: beneficiary's full name
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
XRP009 PROVISIONAL BENEFITS TERMINATED - BENEFICARY PERFORMING SUBSTANTIAL GAINFUL WORK (P18)
(Requested)
Caption: Why Your Provisional Benefits Ended
The Ticket to Work and Work Incentives Improvement Act of 1999 provides that an individual's provisional benefits shall end if the individual performs substantial gainful work. The evidence in (1) case shows that (2) began performing substantial gainful work in (3) . Accordingly, the last provisional benefit (4) may receive is for the month of (5) .
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your
Choice 2: beneficiary's full name's
Fill-in (2) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (3) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (4) - Systems Generated
Choice 1: you
Choice 2: beneficiary's full name
Fill-in (5) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
XRP010 MEDICAL AND/OR HOSPITAL INSURANCE TERMINATED - PROVISIONAL BENEFITS ENDED (P19)
(Requested)
Caption: Information About Medicare
Since (1) no longer receiving provisional monthly Social Security benefits, we are stopping (2) (3) insurance coverage. This coverage ends the last day of (4) . Please destroy (5) Medicare card after coverage ends.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you are
Choice 2: beneficiary's full name is
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) hospital
Choice 2: (B) hospital and medical
Fill-in (4) - Requested As A Date In Format MM/CCYY
Choice 1: Fifth month following month of request or COM plus 2 months, whichever is earlier
Fill-in (5) - Systems Generated
Choice 1: your
Choice 2: beneficiary full name, possessive
XRP012 PROVISIONAL BENEFITS ENDED - BENFICIARY REACHED FULL RETIREMENT AGE (P16)
(Requested)
Caption: Why Your Provisional Benefits Ended
(1) can no longer receive provisional benefits based on (2) request for reinstatement because benefits related to disability cannot be paid after an individual reaches full retirement age. Our records show that (3) reached full retirement age (4) in (5) . Accordingly, the last provisional benefit (6) may receive is for the month of (7) .
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary’s Full Name
Choice 2: You
Fill-in (2) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
Fill-in (3) - Systems Generated
Choice 1: Beneficiary Full Name
Choice 2: you
Fill-in (4) - Systems Generated
Choice 1: null
Fill-in (5) - Systems Generated
Choice 1: Full Retirement Age in the format MM/CCYY
Fill-in (6) - Systems Generated
Choice 1: he
Choice 2: she
Choice 3: you
Fill-in (7) - Systems Generated
Date of termination minus 1 month in the format MM/CCYY
XRP013 MEDICARE CONTINUES - BENEFICIARY AGE 65 OR OLDER (P17)
(Requested)
Caption: Information About Medicare
(1) Medicare coverage will continue because (2) age 65 or older.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Your
Choice 2: Beneficiary's full name, possessive
Fill-in (2) - Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
XRP018 TERMINATION OF PROVISIONAL BENEFITS - LEAD IN UTI (P12)
(Requested)
Caption: Why Your Provisional Benefits Ended
(1) no longer can receive provisional Social Security disability benefits based on (2) request for reinstatement. The last month for which (3) can receive provisional benefits is (4) .
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) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY