BASIC (11-81)

A. Sample form

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B. Preparation of form

Take the name and address from Form SSA-831-U5 shown in the “Name and Address of Claimant” block or Form SSA-3428-U2, Determination of Disallowance Coding Sheet, “Name and Address Information” field in Block 2. If the disability examiner or claims authorizer in ODO requests this notice use Form SSA-L837B.

This notice requires three fill-ins:

1. wage earner's name

2. date given when disability began

3. date of death

The necessary fill-ins for this notice should be shown on Form SSA-831-U5 or Form SSA-3428-U2. If the fill-ins are not shown, return the claim to the individual who initiated the action.

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.