NL 00720: Manual Adjustment, Credit and Award Process (MADCAP) Beneficiary Notice Print Program
TN 4 (08-12)
DIB002 PARTIALLY FAVORABLE DETERMINATION DIB CLAIM (J06)
(Requested)
Caption: The Basis For Our Decision
We recently told you that (1) met the medical requirements to receive Social Security benefits. Now we are writing to tell you that (2) (3) the other requirements. Therefore, (4) (5) for (6) beginning (7) .
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you
Choice 2: Fullname
Fill-in (2) - Systems Generated
Choice 1: he
Choice 2: she
Choice 3: you
Fill-in (3) - Systems Generated
Choice 1: meet
Choice 2: meets
Fill-in (4) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (5) - Systems Generated
Choice 1: qualify
Choice 2: qualifies
Fill-in (6) - Systems Generated
Choice 1: period of disability
Choice 2: monthly disability benefits from Social security
Fill-in (7) - Systems Generated
Choice 1: date of entitlement to disability
DIB003 ONE-CHECK-ONLY AWARD CLOSED PERIOD (J12)
(Requested)
Caption: The Date You Became Disabled
We determined that (1) disability ended (2) . The first month that we could pay (3) benefits was (4) . We could pay (5) through the month (6) disability ended and the next two months. This means that the last month for which (7) entitled to benefits was (8) .
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Name Possessive
Choice 2: your
Fill-in (2) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (3) - Systems Generated\
Choice 1: her
Choice 2: him
Choice 3: you
Fill-in (4) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (5) - Systems Generated
Choice 1: her
Choice 2: him
Choice 3: you
Fill-in (6) - Systems Generated
Choice 1: her
Choice 2: his
Choice 3: your
Fill-in (7) - Systems Generated
Choice 1: she was
Choice 2: he was
Choice 3: you were
Fill-in (8) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
DIB004 SSA PHYSICIAN PARTICIPATED IN DECISION STATE CASE (T28)
(Requested)
Caption: The Basis For Our Decision
Doctors and other trained personnel made the disability decision for us. They work for (1) State but used our rules to make their decision.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your
Choice 2: Fullname possessive
DIB005 SSA PHYSICIAN PARTICIPATED IN DECISION NON STATE CASE (T29)
(Requested)
Caption: The Basis For Our Decision
Our doctors and other trained personnel made the disability decision in (1) case.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your
Choice 2: Full name possessive
DIB072 FIVE MONTH WAITING PERIOD (J09)
(Requested)
Caption: The Date You Became Disabled
(1) to be disabled for 5 full calendar months in a row before (2) can be entitled to benefits. (3) first month of entitlement is (4) .
Fill-in values:
Fill-in (1) Systems Generated
Choice 1: Beneficiary's Name has
Choice 2: She has
Choice 3: He Has
Choice 4: You have
Fill-in (2) Systems Generated
Choice 1: she
Choice 2: he
Choice 3: you
Fill-in (3) Systems Generated
Choice 1: Her
Choice 2: His
Choice 3: Your
Fill-in (4) Requested As A Date In Format Shown Below
Choice 1: MM/CCYY