TN 13 (06-09)

NOTE: This situation does not provide for statutory benefit continuation or Goldberg/Kelly payment continuation. Therefore, a pre-determination notice would have to be sent first. Before sending a final determination and this notice, follow the procedure in DI 27525.005.

4147 modified for fill-ins for disability-blindness

We are writing to you about your Supplemental Security Income payments. We recently looked at (1) claim again to make sure our decision was correct. After reviewing all the information carefully, we are changing our decision. We now find that (2) (3) did not begin until (4) .

Fill-ins:

(1) your/claimant’s name (possessive)

(2) your/his/her

(3) disability/blindness

(4) month, day, year of revised onset, not AOD

If the predetermination due process notice included complete and sufficient personalized language per DI 26530.000, and no changes are needed to the personalized explanation (e.g., no new evidence was submitted that needed to be addressed), there is no need to repeat the personalized language in this reopening determination notice. Otherwise, Enter the Personalized Disability Explanation (PDE) language per DI 26530.020 and DI 26530.055, including a list of the evidence, an explanation of what the evidence shows, and the detailed, personalized reasons for the determination. For additional guidance, see Reopening of Prior Determination DI 27536.015. If merged text is not used, use paragraph 4041, “We have enclosed a page that gives you more details about how we made the decision on your case.” (NL 00708.100).

If concurrent claims are involved, include paragraph 841:

This decision refers only to (1) Supplemental Security Income payments. You will get a separate letter about (2) Social Security Disability Insurance benefits.

Fill-ins:

(1) your/claimant’s name (possessive)

(2) your/his/her

ALS023 – modified to show 789 instead of 561 and to show the SSI pamphlet enclosure.

NOTE: If the revised, later onset is due to work, show “SSA-561, called Request For Reconsideration” instead of the SSA-789, per DI 27501.005C.3.a.

If You Disagree With The Decision

If you disagree with this decision, you have the right to appeal. We will review (1) case and consider any new facts you have. A person who did not make the first decision will decide __(2)__ case. We will review those parts of the decision that you believe are wrong and will look at any new facts you have. We may also review those parts that you believe are correct and may make them unfavorable or less favorable to __(3)__.

• You have 60 days to ask for an appeal in writing.

• The 60 days start the day after you get this letter. We assume you got this letter 5 days after the date on it unless you show us that you did not get it within the 5-day period.

• You must have a good reason for waiting more than 60 days to ask for an appeal.

• You have to ask for an appeal in writing. We will ask you to complete a Form SSA-789-U4, called “Request for Reconsideration – Disability Cessation – Right to Appear.” Contact one of our offices if you want help.

Fill-ins:

(1) your/claimant’s name (possessive)

(2) your/his/her

(3) you/him/her

4066/4067 (combined, and modified to indicate later onset situation)

If the revision to a later onset is due to work or other non-medical reason, delete this caption and text.

How An Appeal Works

A Disability Hearing Officer (DHO) will decide your appeal. We will call this person a DHO in the rest of our letter. The DHO will meet with you before making the decision on your appeal. The meeting works like this:

• The DHO will write you about the time and place for the meeting.

• You can look at your file before the meeting.

• You can tell the DHO when you think you became __(1)__. You can give the DHO more facts and you can bring people to say when you became __(2)__.

• You can have the DHO ask people to come to the meeting and bring important papers. You can question these people at the meeting.

• You do not have to go to the meeting in person. If you do not want to go, you can give the DHO more facts you may have. The DHO will decide your case using these facts and what is now in your file. But if you go to the meeting, it may help the DHO decide your case.

Fill-ins:

(1) disabled/blind

(2) disabled/blind

4069B

If You Want Help With Your Appeal

You can have a friend, representative, or someone else help you. There are groups that can help you find a representative or give you free legal services if you qualify. There are also representatives who do not charge unless you win your appeal. Your local Social Security office has a list of groups that can help you with your appeal.

If you get someone to help you, please let us know. If you hire someone, we must approve the fee before he or she can collect it

4078

If You Have Any Questions

If you have any questions, please call us toll free at 1-800-772-1213, or call your local Social Security office at [FO phone number from DOORS]. We can answer most questions over the phone. You can also write or visit any Social Security office. The office that serves your area is located at:

Fill-in:

[Field Office Address
City, State, ZIP] per DOORS

If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly.

Enclosure:

SSA Pub. No. 05-11008