Form SSA-831-C3/U3 Disability Determination and Transmittal

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SOCIAL SECURITY ADMINISTRATION

Form Approved
OMB No. 0960-0437

DISABILITY DETERMINATION AND TRANSMITTAL

1. DESTINATION

12. DDS CODE

DDS 000

DPB

DOB

010

0 0

0

0

0

3. FILING DATE

I BIC

4. SSN

(if COB or DWB CLAIM)

I

I

5. NAME AND ADDRESS OF CLAIMANT (include ZIP Code)

I
I

-

-

I

6. WE'S NAME (IF COB OR OWB CLAIM)
7. TYPE CLAIM (Title II)
DIB

FZ

0

D

DWB

CDB-D

CDB-R

RD-R RD-D

0

0

D

0

0

RD

P-R

poD MOFE

0

0

0

8. TYPE CLAIM (Tille XVI)

001
9. DATE OF BIRTH

Doc

o BC

o BS

OBI

11. REMARKS

10. PRIOR ACTION

DpO

DPT

12. DISTRICT-BRANCH OFFICE ADDRESS (include ZIP Code)

13. OO-BO REPRESENTATIVE

DDS

0

DO-BO
CODE

llA.

114. DATE

Presumptive
o Disability

.

111B.
D

Impairment

DETERMINATION PURSUANT TO THE SOCIAL SECURITY ACT AS AMENDED
A.

Disability
o Began

I
I
I

Disability
Ceased

I

B.
D

17. DIARY TYPEI

ODY SYS.

16A. PRIMARY DIAGNOSIS

15. CLAIMANT DISABLED

0

I

MO.tyR.

IREASON
19. CLAIMANT NOT DISABLED
Through Date of
A. D Current Determination

Not Disab. for Cash
Bene. Purp.

lB. D

Disab. for Cash Benefit Purp.
Beg.

B. D

C. D

Through

o YRS.

pCC YRS.

20. VOCATIONAL BACKGROUND

SCIN
22. REG-BASIS COO, 23. MED LIST NO. 24. MOB CODE 125. REVISED 25A.

A. D

DET D

L1ST~r'

Initial

C.

B.

Recon
B. D

Before Age 22
(COB only)

21. VRACTION
SCOUT
B. D

A·D

26.

rODE NO.

I

18. CASE OF BLINDNESS AS DEFINED IN SEC. 1614(a)(2Y(216)(i)
A.

16B. SECONDARY DIAGNOSIS

rODE NO.

Recon DHU

c.

e.c

Appeals Council U.S. District Court

AU Hearing

D

E·D

D·D

D.

Prev Ref

E.

F·D

IF.

NO.

7. RATIONALE
D
28.

See Attached
SSA-4268-U4/C4

A. D Period of Disability

29. LTRiPAR NO.

D

Check if Vocational ~

Rule Met. Cite Rule

8. D Disability Period

C.

0

30. DISABILITY EXAMINER-DDS

AND D.

Estab Beg
31. DATE

0

Continues

E. D

Term

32. PHYSICIAN OR MEDICAL SPEC. SIGNATURE

33. DATE

32B. SPEC. CODE

32A. PHYSICIAN OR MEDICAL SPEC. NAME (Stamp, Print or Type)

34. REMARKS

MULTIPLE IMPAIRMENTS
CONSIDERED

34A.
COMBINED MULTIPLE
NONSEVERE-SEVERE
34B.
COMBINED MULTIPLE
NONSEVERE·
NONSEVERE

.,
35. BASIS CODE

36. REV. DET. 37. SSA REPRESENTATIVE
CODES

SSA
CODE

Form SSA-831 C3IU3 (12-2001) ef (01-2006)

Electronic Input:

FOLDER COPY

D

DECISION

38. DATE

D

CASE CONTROL

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PRIVACY ACT/PAPERWORK ACT NOTICE

We are authorized to collect this information under Sections 221 (a) and (b) of the Social Security Act and
Sections 404.1615(d) and 416.10 15 (d) of the Code of Federal Regulations. The information will be used to
determine eligibility for benefits and for program evaluation and management. You are not required to complete
this form, however, failure to do so could affect the claimants eligibility for benefits.
We may also use the information you give us when we match records by computer. Matching programs
compare our records with those of other Federal, State, or local government agencies. Many agencies may use
matching programs to find or prove that a person qualifies for benefits paid by the Federal government. The law
allows us to db this even if you do not agree to it.
Explanations about these and other reasons why information you provide us may be used or given out are
available in Social Security Offices. If you want to learn more about this, contact any Social Security Office.

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. §
3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these
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questions unless we display a valid Office of Management and Budget control number. We estimate that it wil
take about 15 minutes to read the instructions, gather the facts, and answer the questions. SEND OR BRING
THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed
under U. S. Government agencies in your telephone directory or you may call Social Security at
1-800-772-1213. You may send comments on our time estimate above to: SSA, 6401 Security Blvd.,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the

completed form.

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Form SSA-831 C3IU3 (12-2001) ef (01-2006)