TN 73 (06-16)

Document Identifier: INT701

A. Requesting instructions

The targeted audience for this notice is disabled number holders, disabled widow(er)s, and disabled children who are eligible for interim benefit payments.

Refer to NL 00703.005 for ALS020, CTDO, and 3901C text.

B. Exhibit letter

We are writing to tell you that we will pay (1) temporary disability benefits. The first month we can pay (2) is (3).

Why We Will Pay (4)

We sent (5) a letter stating that we are reviewing the disability decision made on (6) case. We told (7) that we had 110 days after the date of the disability decision to make a final decision.

We said if we did not make a final decision in the 110 days, we would pay (8) temporary disability benefits. We are paying (9) temporary disability benefits until we make a final decision.

What We Will Pay And When

We will pay (10) $ (11). This is the amount of (12) temporary disability benefits for (13) through (14).

Beginning (15), we will pay (16) $ (17) each month until we make a final decision on (18) case.

If You Disagree With This Decision

ALS020

We Will Tell You About The Final Decision

We will send you another letter when we make a final disability decision on (19) claim.

If we find (20) disabled, we will tell you the date (21) for disability benefits and the total amount (22) due. We will subtract the amount of temporary disability benefits that we have already paid (23) from this total.

If we find (24) not disabled under our rules, we will explain why we cannot continue to pay (25), and stop (26) temporary disability benefits.

You will receive another letter about (27) application for Supplemental Security Income payments.

If You Have Any Questions

CTDO

3901C

C. Fill-ins for the notice

1. you/beneficiary's full name, possessive in format: Robert L. Smith's

2. you/him/her

3. month/year (MM/YYYY) first month benefit is effective

4. you/beneficiary's full name, possessive in format: Robert L. Smith's

5. you/him/her

6. your/his/her

7. you/him/her

8. you/him/her

9. you/him/her

10. you/him/her

11. Amount of past-due benefits

12. your/his/her

13. month/year (MM/YYYY) first month benefit is effective

14. month/year (MM/YYYY) last month included in past-due benefit calculation

15. month/year (MM/YYYY) first month recurring benefit is effective

16. you/him/her

17. Amount of monthly benefit

18. your/his/her

19. your/his/her

20. you/him/her

21. you qualify/he qualifies/ she qualifies

22. you are/he is/she is

23. you/him/her

24. you/him/her

25. you/him/her

26. your/his/her

27. your/his/her/NULL