TN 1 (02-11)

A. How to Complete the SSA-831-U5

Complete the SSA-831-U5 (Disability Determination and Transmittal) for any Title XVI claim with the following exceptions:

Item Action

15 See DI 23515.005 for onset date instruction

18B Same date as item 15

27 Be alert that change in onset is determined from the alleged onset of disability, not the filing date, as in regular Title XVI claims.

B. How to complete rationales and notices

1. Rationale preparation

Use the same requirements for technical rationales, as for regular Title XVI claims.

2. Notice Preparation

• Non-citizen

Do not release a personalized disability notice in unfavorable determinations.

Prepare an attachment for use by the field office (FO) as part of an overall non-citizen denial notice; and

Place the attachment in the file.

The FO releases an overall notice of determination, including information about the disability determination.

• Aged non-citizen age 65 and older

The disability determination is only one of the criteria for eligibility. Do not release a personalized disability notice in unfavorable determinations.

Prepare an attachment to be used by the field office as part of an overall non-citizen denial notice; and

Place the attachment in the file.

The FO releases an overall notice of determination including information about the disability determination.

3. Preparing the attachment

• Non-citizen

The attachment has the individual's name in the upper left hand corner, the Social Security Number in the upper right hand corner, and the title “INFORMATION ABOUT THE DISABILITY DECISION” centered below those entries (see DI 23515.010 for an example).

The attachment contains the following headings that are included in personalized disability notices: “The Decision on Your Case,” “About the Decision,” “The Disability Rules,” and “Information About Substantial Work. “

• Aged non-citizen age 65 and older

The attachment has the individual's name in the upper left hand corner, the SSN in the upper right hand corner, and the title centered below those entries (see DI 23515.010 for an example).

The attachment contains the following headings that are included in personalized disability notices: “The Decision on Your Case,” “About the Decision,” “The Disability Rules,” and “Information About Substantial Work.” also contains information normally contained under those headings.

For a reconsideration affirmation, use the standard Form SSA L1130-U2, SSI Notice of Recon-Disability.

NOTE: For a reconsideration affirmation, use the standard Form SSA L1130-U2, SSI Notice of Recon-Disability.

C. Exhibits for non-citizen cases

Exhibit 1 (model language for DDS letter to DHS)

DDS Letterhead

Department of Homeland Security District Office
(Address)

We are writing to obtain medical evidence on behalf of (claimant's name and address) who has applied for payments based on disability or blindness under the Supplemental Security Income provision of Title XVI of the Social Security Act. This agency is responsible for determining, on behalf of the Commissioner of the Social Security Administration, whether the claimant is disabled or blind and whether the onset of disability or blindness occurred before or after admission to the United States for permanent residence.

To make such a determination, we need a copy of Form OF-157 (Medical Examination of Visa Applicants) and/or any other medical reports contained in your file. The claimant's authorization is enclosed.

The claimant was admitted to the United States for permanent residence on _______ (date), at ________ (place of entry) and was going to live at ­­­­­­­­­­­­_________ (address). His or her non-citizen registration number is       .

Your prompt response will help assure a speedy decision on this claim. If you have any questions, please call this agency collect. Thank you for your cooperation.

Sincerely yours,

Chief Medical Consultant

Enclosure

Exhibit 2 – Disability Determination Notice – Non Citizens Age 65 and Older [

(Claimant Name)(SSN)

INFORMATION ABOUT THE DISABILITY DECISION

The Decision on Your Case

{For Personalized Disability Language instructions, see DI 26530.000 ff.}

About the Decision

Doctors and other trained staff looked at your case and made this decision. They work for the State but used our rules.

Please remember that there are many disability programs, both government and private, that use different rules. A person may be receiving benefits under another program and still not be entitled under our rules. This may be true in your case.

The Disability Rules

You must meet certain rules to qualify for SSI payments based on disability. Your health problems must:

keep you from doing any kind of substantial work (described below), and

last, or be expected to last, for at least 12 months in a row, or

be expected to result in death

You must meet certain rules to qualify for SSI payments based on blindness.

Your eyesight must be no better than 20/200 in the better eye with the use of a corrective lens, or

Your visual fields must be restricted to 20 degrees or less.

You can qualify for SSI benefits due to blindness even if you can do substantial work.

Information About Substantial Work

Generally, substantial work is physical or mental work you are paid to do. Work can be substantial even if it is part-time. To decide if your work is substantial, we consider the nature of the job duties, the skills and experience you need to perform the job, and your earnings.

Usually, we find that your work is substantial, if your gross earnings average over $1000 per month after we deduct allowable amounts. Your work may be different from your work before your health problems began. It may not be as hard to do and your pay may be less. However, we may still find that your work is substantial under our rules.

If you are self-employed, we consider the kind and value of your work, including your part in the management of the business, as well as your income, to decide if your work is substantial.

Exhibit 3 (map of DHS regional and district areas)

 View PDF Version

Exhibit 4 (DHS regional offices)

Exhibit 5 (DHS servicing offices by state)

Exhibit 6 (DHS district offices)

DHS District Offices