BASIC (11-81)

A. Sample form

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B. Preparation of form

Take the name and address from Form SSA-831-U5 or Form SSA-3428-U2, Determination of Disallowance Coding Sheet, “Name and Address Information” field in Block 2.

There are no fill-ins required for this notice.

NOTE: Personalized disability notice procedures implemented July 1, 1981, require that Forms SSA-4268-U6/C6 be attached to unfavorable disability form notices. In addition to preparing this form notice according to instructions, the typist must:

1. Type the personalized and technical rationales on the Form SSA-4268-U6 or SSA-4268-C6.

2. Prepare appropriate rider (or include paragraphs on form notice if there is room).

3. Assemble form notice, personalized rationale and the rider stapled together in that order, with envelope for mailing.