TN 3 (11-05)

A. Exhibit -- Potential Interim Benefit Case (Information Sheet)

_____________________________________________________________________

                                        Potential Interim Benefit Case

Claimant’s SSN: ____-___-___ Wage Earner’s SSN:___-___-___

Claimant’s Name: ____-___-___ Telephone:___-___-___

In Care of:______

Street:______ City:_______ State:_______ Zip:______

[ ] Title II (Only)    [ ] Title XVI (Only)     ([ ] SSI Child)     [ ] Concurrent Title II and XVI

ALJ:_____ Hearing Office:________

ALJ Decision Date __/__/__ (mm/dd/yyyy) 110 days: __/__/__ To OAO, Exec. Dir. Ofc.: __/__/__

WC:    [ ]Yes    [ ]No

Application Date: __/__/__ Onset Date Established: __/__/__

Date of Birth: __/__/__                         Remand Date: __/__/__

Representative’s Name: ___ Telephone (__)__-__

Street:______ City:_______ State:_______ Zip:______

Prisoner Suspension   [ ]Yes    [ ]No Branch: ______

Comments:____

___________________________________________________________________

___________________________________________________________________

Contact to Start: __/__/__ Contact to Stop: __/__/__

Office Contacted:

Title II (Office/FAX)                        Title XVI:____

                                                      E-Mail:_____

TOELs=

Additional Comments:____

_____________________________________________________________________

B. Exhibit -- Potential Interim Benefit Case - OAO E-Mail Message to FO

Sample of message to be sent:

To... |NY FO Gloversville

Subject: Interim Benefits Case – John Smith, 123-00-6789 – ACTION – SSI Case

Please process case within 10 working days of receipt

(Sample IB Sheet)

John Smith 1...

Martin Travis

Program Analyst

Office of Appellate Operations

Office of Disability Adjudication and Review

Please follow POMS instructions in SI 02007.001.