TN 4 (02-95)

A. Introduction

Since the same captions and paragraphs may appear on the SSA-L8100-U2, SSA-L8151-U2 and SSA-L8155-U2, only one chart for completing these forms is necessary. Paragraphs have date fill-ins that make them suitable for covering retroactive and/or prospective changes.

B. Procedure

1. Standard Opening

Look for the standard opening paragraph preprinted on the form. Follow the standard opening paragraph with paragraph 2002 (NL 00804.115) and paragraph 2016 (NL 00804.105). Modify paragraph 2002 as necessary. Note that paragraph 2016 has headings for a chart to show payment changes.

2. Appeal Rights

If you manually prepare an SSA-L8100-U2, SSA-L8151-U2, or SSA-L8155-U2, do not print on the reverse side of a page.

NOTE: Appeal rights must appear on the front of a page and precede the closing and signature.