Application for Mother's of Father's Insurance Benefits / MCS

MCS 3.7 TRANSFER TO: XXXX
EARNINGS
EARN
NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS SSSSSSSSSS
LIST ALL EARNINGS AND TYPES FOR SSSS SSSS SSSS
TYPES ARE:1=FICA WAGES 2=SEI 3=EMPLOYEE REPORTED TIPS 4=RR LAG
PROOF CODES ARE: P=PROVEN R=READILY AVAILABLE N=NOT
AVAILABLE D=DELETED LAG
[1-C] [2-C] [3-C] [4-C]
YEAR TYPE AMOUNT PRF
99 9 99999999 X
99 9 99999999 X
99 9 99999999 X
99 9 99999999 X
99 9 99999999 X
99 9 99999999 X
99 9 99999999 X
99 9 99999999 X
99 9 99999999 X
99 9 99999999 X
99 9 99999999 X
99 9 99999999 X
[5-C]
DO YOU WISH US TO COMPUTE YOUR BENEFITS AND COMPLETE YOUR
CLAIM
WITHOUT USING UNPOSTED RECENT EARNINGS (Y/N): X

TRANSFER TO: XXXX RSDHI CLAIMS APPLICATION
APPL
[1-M]
NH NAME: XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XXXX
[2-M]
[3-M]
SSN: SSSSSSSSS SEX: X
NH BIRTHDATE: 99999999
[4-M]
[5-C]
PROOF (A/B/C/F/Q): X
PROOF TYPE (P/H/N/O): X
[6-M]
SELECT CLAIM TYPE(S): 9 9 9 1. RETIREMENT 4. AUXILIARY
7. AGE 72
2. DISABILITY 5. UNINS MED ONLY 8. ESRD
[7-C]
3. SURVIVOR 6. LUMP SUM
ABBREVIATED APPLICATION: X
CLAIMANT (IF DIFFERENT)
[8-C]
NAME: XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XXXX
[9-C]
[10-C]
[11-C]
SSN: 999999999 SEX: X
BIRTHDATE: 99999999
[12-C]
[13-C]
PROOF (A/B/C/F/Q): X
PROOF TYPE (P/H/N/O): X
[14-C]
[15-C]
RELATIONSHIP TO NH: 9 1. SPOUSE
(SUBSEQUENT CLAIM: 9 ) 1. RIB
2. SPOUSE WITH CHILD IN CARE
2. DIB
3. CHILD
APPLICANT (IF DIFFERENT) 4. DEPENDENT PARENT
[16-C]
NAME: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[17-C]
[18-C]
[19-C]
SSN: 999999999 EIN: 999999999 WILL APPLICANT BE ENTERED IN RPS (Y/N): X

MCS 3.4
NH MARRIAGE
NMAR
NH SSSSSSSSS SSSSS SSSSSSSSSS
CL SSSSSSSSS SSSSS SSSSSSSSSS
[1-M]
[2-C]
[3-M]
SPOUSE''S FIRST NAME: XXXXXXXXXXXXXXX MI: X LAST NAME:
XXXXXXXXXXXXXXXXXXXX
[4-C]
SPOUSE''S SSN: 999999999
[6-C]
[5-C]
SPOUSE 'S BIRTHDATE (MMDDYYYY): 99999999
IF BIRTHDATE UNKNOWN, AGE:
999
[7-M]
[8-M]
MARRIAGE DATE (MMDDCCYY): 99999999
PROOF (Y/N): X
[9-C]
MARRIAGE OCCURRED IN WHAT STATE/FOREIGN COUNTRY: XX
[10-C]
SELECT MARRIAGE TYPE: 9 1=CLERGY/PUBLIC OFFICIAL
2=COMMON LAW
3=OTHER CEREMONIAL
4= DEEMED.
[11-M]
[12-C]
[13-C]
MARRIAGE ENDED (Y/N): X
MARRIAGE END DATE(MMDDCCYY): 99999999
PROOF (Y/N): X
[14-C]
STATE OR FOREIGN COUNTRY WHERE MARRIAGE ENDED: XX
[15-C]
SELECT REASON: 9 1=DEATH
2=DIVORCE
3=ANNULMENT OR VOIDABLE
4=PUTATIVE
5=VOID/VOIDED
[16-C]
IF SPOUSE DECEASED, DATE OF DEATH (MMDDCCYY): 99999999
[17-M]
[18-C]
OTHER MARRIAGES (Y/N): X
DELETE SCREEN (Y/N): X
[19-D]
[20-C]
PAGE: X
TRANSFER TO: XXXX

MCS TRANSFER TO: XXXX
IDENTIFICATION
IDEN
NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS SSSSSSSSSS
[1-M]
LANGUAGE SPOKEN AND WRITTEN IS ENGLISH (Y/N): X
[2-M]
[3-C]
[4-C]
BIRTH CITY: XXXXXXXXXXXXXXX BIRTH STATE: XX BIRTH COUNTRY: XX
[5-M]
[6-M]
RECORD OF BIRTH BEFORE AGE 5:
PUBLIC (Y/N): X RELIGIOUS (Y/N): X
[7-C]
OTHER NAMES USED: XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XXXX
XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XXXX
XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XXXX
XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XXXX
XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XXXX
[8-M]
[9-M]
[10-M]
EVER MARRIED (Y/N): X CURRENTLY MARRIED (Y/N): X DEP CHILDREN (Y/N): X
[11-M]
WORK OR EARNINGS IN 19SS 19SS 19SS 19SS (Y/N): X
[12-M]
[13-C]
DISABLED IN LAST 14 MONTHS (Y/N): X
ONSET DATE: 99999999
[14-C]
IF YES, APPLYING FOR DISABILITY ON THIS ACCOUNT (Y/N): X
[15-M]
[16-M]
[17-M]
PRIOR APPLICATION FOR RSDI (Y/N): X FOR SSI (Y/N): X FOR MEDICARE (Y/N): X
[18-C]
[19-C]
CROSS REFERENCE SSN: 999999999
STAT: XX SSN: 999999999 STAT: XX
[20-C]
[21-C]
NH NAME IN PRIOR APPLICATION: XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX SSN: 999999999
NH NAME IN PRIOR APPLICATION: XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX SSN: 999999999
[22-C]
MULTIPLE SSN: 999999999 999999999 999999999 999999999 999999999

mcs
TRANSFER TO: XXXX ADDITIONAL BENEFITS
ADDB
NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS SSSSSSSSSS
[1-M]
ACTIVE U.S. MILITARY/RESERVE/NATL GUARD SERVICE AFTER SEPT 7 1939 (Y/N): X
[2-M]
[3-C]
WORKED IN RR FOR 5 YEARS OR MORE (Y/N): X
SPOUSE (Y/N):X
[4-M]
[5-C]
RECEIVING RR RETIREMENT PENSION/ANNUITY (Y/N): X SPOUSE (Y/N): X
[6-M]
[7-C]
COVERED UNDER FOREIGN SSA (Y/N): X
COUNTRY: XXXXXXXXXX IF COVERED,
[8-C]
[9-C]
FILING FOR FOREIGN SSA (Y/N): X
REQUIRES FOREIGN QC'S FOR US FILING (Y/N): X
[10-C]
[11-C]
SPOUSE COVERED UNDER SSA OF OTHER COUNTRY (Y/N): X COUNTRY: XXXXXXXXXX
[12-M]
[13-C]
CIVILIAN EMPLOYEE OF FEDERAL GOVT IN JAN 1983 (Y/N): X SPOUSE (Y/N): X
[14-M]
[15-C]
JAPANESE INTERNEE (Y/N): X
VOW OF POVERTY (Y/N):
[16-M]
QUALIFY FOR US FED/STATE/LOCAL GOVT PENSION BASED ON ANY WORK YOU PERFORMED
which was NOT COVERED UNDER SSA (Y/N): x
[17-M]
CURRENTLY ENTITLED TO A PENSION NOT COVERED UNDER SSA (Y/N): X
[18-C]
IF NO, DO YOU EXPECT TO BE ENTITLED TO A PENSION NOT COVERED UNDER SSA IN THE FUTURE (Y/N): X
[19-C]
IF YES, SHOW FUTURE ENTITLEMENT DATE (MMYY): 9999
[20-C]
FILING FOR MEDICARE ONLY, RESTRICTING MONTHLY BENEFITS (Y/N): X
[21-C]
WILL MEDICARE APPLY: 9 1. YES 2. NO 3. ALREADY ENROLLED ON ANOTHER SSN
[22-M]
IF CLAIMANT IS FILING AS A SURVIVING SPOUSE, IS CLAIMANT
FILING FOR BENEFITS ON OWN RECORD (Y/N): X

COMM
BENEFICIARY MARRIAGE
BMAR
[1-D]
[2-D]
[3-D]
NH: SSSSSSSSS SSSSS SSSSSSSSSS BN: SSSSSSSSS SSSSS SSSSSSSSSS PIC: SSS
[4-M]
[5-M] [6-M]
*SPOUSE’S FIRST NAME: XXXXXXXXXXXXXXX MIDDLE: X *LAST: XXXXXXXXXXXXXXXXXXXX
[7-O]
SPOUSE’S SSN: XXXXXXXXX
[8-O]
[9-O]
SPOUSE’S BIRTHDATE (MMDDCCYY): 99999999 iF BIRTHDATE UNKNOWN, AGE: 999
[10-M]
[11-M]
*MARRIAGE DATE (MMDDCCYY): 99999999 *PROOF (Y/N): x
[12-O]
MARRIAGE OCCURRED IN WHAT STATE/FOREIGN COUNTRY: XX
[13-M]
*SELECT MARRIAGE TYPE: 9 1=CLERGY/PUBLIC OFFICIAL 3=OTHER CEREMONIAL
2=COMMON LAW
4=DEEMED.
[14-O]
SELECT SPECIAL RELATIONSHIP: 9 1=216B1 2=216F1 3=202C2 4=216K
[15-O]
PROTECTED MARRIAGE (Y/N): x
[16-C]
[17-C]
MARRIAGE END DATE (MMDDCCYY): 99999999 PROOF (Y/N): x
[18-C]
SELECT MARRIAGE END REASON: 9
1=DEATH 2=DIVORCE 3=ANNULMENT OF VOIDABLE 4=PUTATIVE 5=VOID/VOIDED.
[19-C]
STATE/FOREIGN COUNTRY WHERE MARRIAGE ENDED: XX
[20-O]
IF SPOUSE DECEASED, DATE OF DEATH (MMDDCCYY): 99999999
[21-M]
*oTHER MARRIAGES (Y/N): x
[22-O]
DELETE THIS OCCURRENCE OF DATA (Y/N): x
[23-O]
[24-O]
ADD NEW OCCURRENCE (Y/N): x
REVIEW PRIOR OCCURRENCES (Y/N): x
[25-D]
[26-O]
PF1 HELP AVAILABLE
TRANSFER TO: XXXX

Ln
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0
1
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*
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E
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S
E
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V
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1
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2345678901234567890123456789012345678901234567890123456789012345678901234567890
MCS
CLAIM CONTACT METHOD DATA
CCMD SC95
NH: SSSSSSSSS SSSSS SSSSSSSSSS
CL: SSSSSSSSS SSSSS SSSSSSSSSS
CONTACT METHOD FOR ESTABLISHING APPLICATION
*CLAIM TYPE: SSSSSS CONTACT METHOD 1: 99
CLAIM TYPE: SSSSSS CONTACT METHOD 2: 99
CLAIM TYPE: SSSSSS CONTACT METHOD 3: 99
CONTACT METHOD (CM) VALUES AND MEANINGS:
1. TELEPHONE -CLAIM INITIATED OVER THE PHONE, USUALLY BY APPOINTMENT
2. VISIT
-CLAIM INITIATED IN PERSON WITH THE CLAIMANT
3. MAIL
-RECEIVED PAPER APPLICATION IN THE MAIL AND LOADED IN MCS
4. INTERNET
-CLAIM STARTED AND COMPLETED ON THE INTERNET
5. ICT
–CLAIM ORIGINATED THROUGH 800 NUMBER CALL AND REFERRED TO
IMMEDIATE CLAIMS TAKING (ICT) UNIT
6. OTHER
-NO OTHER CM VALUE IS CURRENTLY APPROPRIATE
*UNSATISFIED FELONY WARRANTS FOR YOUR ARREST? (Y/N): A
*UNSATISFIED FEDERAL/STATE WARRANTS FOR VIOLATION OF PROBATION/PAROLE? (Y/N): A
INTERNET:
*DO YOU WANT TO CHECK THE STATUS OF YOUR CLAIM USING THE INTERNET? (Y/N): A
*IF AWARDED, DO YOU WANT A PASSWORD TO USE SSA INTERNET/PHONE SERVICE? (Y/N): A
SELECT MAILING METHOD (BLIND NOTICE INFORMATION) TYPE: 9
1=CERTIFIED MAIL
2=TELEPHONE CONTACT
3=REGULAR MAIL.
PF1 FOR HELP
TRANSFER TO: XXXX
**************(LINE 23 RESERVED FOR APPLICATIONS INFORMATION)*****************
**************(LINE 24 RESERVED FOR OPERATING SYSTEMS INFORMATION)***********

Current CADR Screen:
Ln
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7
8
9
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0
1
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0
L
U
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N
*
O
N
E

1
2
3
4
5
6
7
8
2345678901234567890123456789012345678901234567890123456789012345678901234567890
MCS
CLAIMANT MAILING ADDRESS
CADR SC90
NH: SSSSSSSSS SSSSS SSSSSSSSSS
CL: SSSSSSSSS SSSSS SSSSSSSSSS

*ADDRESS 1: PPPPPPPPPPPPPPPPPPPPPP
ADDRESS 3: PPPPPPPPPPPPPPPPPPPPPP
*CITY: PPPPPPPPPPPPPPPPPPPPPP
STATE & COUNTY CODE: PPPPPP

ADDRESS 2: PPPPPPPPPPPPPPPPPPPPPP
ADDRESS 4: PPPPPPPPPPPPPPPPPPPPPP
STATE: PP
ZIP: PPPPP
COUNTY: XXXXXXXXXXXXXXX

COUNTRY: PPPPPPPPPPPPPPPPPPPPPP
CONSULAR CODE: PPP
R FOREIGN POSTAL ZONE: PPPPPPPPPPPPPPP
E
S
E
R DIRECT DEPOSIT ROUTING TRANSIT NUMBER: 999999999
ACCOUNT TYPE (C/S): A
V DEPOSITOR ACCOUNT NUMBER: 99999999999999999
E
D
DOMESTIC PHONE: PPPPPPPPPP
FOREIGN PHONE: PPPPPPPPPPPPPPP
TRANSFER TO: XXXX
**************(LINE 23 RESERVED FOR APPLICATIONS INFORMATION)*****************
**************(LINE 24 RESERVED FOR OPERATING SYSTEMS INFORMATION)***********

Proposed CADR screen showing changes for UDD – Direct Express.
Ln
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7
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2345678901234567890123456789012345678901234567890123456789012345678901234567890
MCS
CLAIMANT MAILING ADDRESS
CADR SC90
NH: SSSSSSSSS SSSSS SSSSSSSSSS
CL: SSSSSSSSS SSSSS SSSSSSSSSS

*ADDRESS 1: PPPPPPPPPPPPPPPPPPPPPP
ADDRESS 3: PPPPPPPPPPPPPPPPPPPPPP
*CITY: PPPPPPPPPPPPPPPPPPPPPP
STATE & COUNTY CODE: PPPPPP

ADDRESS 2: PPPPPPPPPPPPPPPPPPPPPP
ADDRESS 4: PPPPPPPPPPPPPPPPPPPPPP
STATE: PP
ZIP: PPPPP
COUNTY: XXXXXXXXXXXXXXX

COUNTRY: PPPPPPPPPPPPPPPPPPPPPP
FOREIGN POSTAL ZONE: PPPPPPPPPPPPPPP
BANK ACCOUNT (Y/N): X

CONSULAR CODE: PPP
DIRECT EXPRESS (Y/N): X

DIRECT DEPOSIT ROUTING TRANSIT NUMBER: 999999999
DEPOSITOR ACCOUNT NUMBER: 99999999999999999
DOMESTIC PHONE: PPPPPPPPPP

ACCOUNT TYPE (C/S): A

FOREIGN PHONE: PPPPPPPPPPPPPPP

TRANSFER TO: XXXX
**************(LINE 23 RESERVED FOR APPLICATIONS INFORMATION)*****************
**************(LINE 24 RESERVED FOR OPERATING SYSTEMS INFORMATION)***********

Current CADR Screen:
Ln
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2345678901234567890123456789012345678901234567890123456789012345678901234567890
MCS
CLAIMANT MAILING ADDRESS
CADR SC90
NH: SSSSSSSSS SSSSS SSSSSSSSSS
CL: SSSSSSSSS SSSSS SSSSSSSSSS

*ADDRESS 1: PPPPPPPPPPPPPPPPPPPPPP
ADDRESS 3: PPPPPPPPPPPPPPPPPPPPPP
*CITY: PPPPPPPPPPPPPPPPPPPPPP
STATE & COUNTY CODE: PPPPPP

ADDRESS 2: PPPPPPPPPPPPPPPPPPPPPP
ADDRESS 4: PPPPPPPPPPPPPPPPPPPPPP
STATE: PP
ZIP: PPPPP
COUNTY: XXXXXXXXXXXXXXX

COUNTRY: PPPPPPPPPPPPPPPPPPPPPP
CONSULAR CODE: PPP
R FOREIGN POSTAL ZONE: PPPPPPPPPPPPPPP
E
S
E
R DIRECT DEPOSIT ROUTING TRANSIT NUMBER: 999999999
ACCOUNT TYPE (C/S): A
V DEPOSITOR ACCOUNT NUMBER: 99999999999999999
E
D
DOMESTIC PHONE: PPPPPPPPPP
FOREIGN PHONE: PPPPPPPPPPPPPPP
TRANSFER TO: XXXX
**************(LINE 23 RESERVED FOR APPLICATIONS INFORMATION)*****************
**************(LINE 24 RESERVED FOR OPERATING SYSTEMS INFORMATION)***********

Proposed CADR screen showing changes for UDD – Direct Express.
Ln
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0
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2345678901234567890123456789012345678901234567890123456789012345678901234567890
MCS
CLAIMANT MAILING ADDRESS
CADR SC90
NH: SSSSSSSSS SSSSS SSSSSSSSSS
CL: SSSSSSSSS SSSSS SSSSSSSSSS

*ADDRESS 1: PPPPPPPPPPPPPPPPPPPPPP
ADDRESS 3: PPPPPPPPPPPPPPPPPPPPPP
*CITY: PPPPPPPPPPPPPPPPPPPPPP
STATE & COUNTY CODE: PPPPPP

ADDRESS 2: PPPPPPPPPPPPPPPPPPPPPP
ADDRESS 4: PPPPPPPPPPPPPPPPPPPPPP
STATE: PP
ZIP: PPPPP
COUNTY: XXXXXXXXXXXXXXX

COUNTRY: PPPPPPPPPPPPPPPPPPPPPP
FOREIGN POSTAL ZONE: PPPPPPPPPPPPPPP
BANK ACCOUNT (Y/N): X

CONSULAR CODE: PPP
DIRECT EXPRESS (Y/N): X

DIRECT DEPOSIT ROUTING TRANSIT NUMBER: 999999999
DEPOSITOR ACCOUNT NUMBER: 99999999999999999
DOMESTIC PHONE: PPPPPPPPPP

ACCOUNT TYPE (C/S): A

FOREIGN PHONE: PPPPPPPPPPPPPPP

TRANSFER TO: XXXX
**************(LINE 23 RESERVED FOR APPLICATIONS INFORMATION)*****************
**************(LINE 24 RESERVED FOR OPERATING SYSTEMS INFORMATION)***********

MCS
TRANSFER TO: XXXX REMARKS SCREEN
RMKS
NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS SSSSSSSSSS
[1-C]
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX
[3-C]
[2-C]
MORE (Y/N): X
GO TO RPS (Y/N): X
PAGE S

MCS 3.6 TRANSFER TO: XXXX WORK DEDUCTIONS/ELECTION OPTION
DEME
NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS SSSSSSSSSS
LIST TYPES, AMOUNTS, PRFS, AND NON-SERVICE MONTHS FOR SSSS SSSS SSSS
TYPES ARE: 1=WAGES 2=SEI 3=WAGES AND SEI PRF: P=PERM
NON-SERVICE MONTHS PLACE AN X UNDER ALL, NONE, OR EACH MONTH THAT APPLIES
[1-C] [2-C] [3-C]
[4-C][5-C]
YEAR TYPE AMOUNT ALL NONE 01 02 03 04 05 06 07 08 09 10 11 12 PRF FY ENDS
SS S SSSSSSSSS X X X X X X X X X X X X X X X 99
SS S SSSSSSSSS X X X X X X X X X X X X X X X 99
SS S SSSSSSSSS X X X X X X X X X X X X X X X 99
[6]
IF OVER MAX OR NONCOVERED EARNINGS INVOLVED, CORRECT ABOVE AMOUNTS.
[7-M]
SPECIAL PAYMENTS INVOLVED (Y/N): X IF YES, CORRECT ABOVE
[9-C]
[8-C]
FOREIGN WORK SERVICE MONTHS
(YY) ALL 01 02 03 04 05 06 07 08 09 10 11 12
99 X X X X X X X X X X X X X
99 X X X X X X X X X X X X X
99 X X X X X X X X X X X X X
[10-M]
[11-C]
ELECTION/ENTITLEMENT OPTION: X DATE(MMYY): 9999
A. MOST ADVANTAGEOUS MONTH
B. EARLIEST MONTH WITHOUT REDUCTION
C. CLAIMANT'S CHOSEN MONTH
D. UNREDUCED CLAIMANT
E. NOT APPLICABLE (DIB AUX SPOUSE WHO MEETS CRITERIA)
F. OTHER: SPECIAL REASON SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS

COMM

GOVERNMENT PENSION
GPI1
SS: SSS-SS-SSSS SSSSS SSSSSSSSSS

[1-M]
*GOVERNMENT PENSION IDENTIFICATION NUMBER: XXXXXXXXXXXXXXX
[2-M]
*ENTER GOVERNMENT PENSION TYPE: 9
1=FEDERAL 2=STATE 3=LOCAL 4=MILITARY.
[3-M]
*IS THIS GOVERNMENT PENSION BASED ON ANOTHER PERSON'S EARNINGS (Y/N): X
[4-M]
*IS THIS GOVERNMENT PENSION BASED ONLY ON EMPLOYMENT COVERED UNDER SS
(Y/N): X
[5-C]
[6-C]
EARLIEST DATE ELIGIBLE FOR THIS PENSION (MMDDCCYY): 99999999 PROOF (Y/N): X
[7-C]
[8-C]
PERIODIC PAYMENTS AWARDED (Y/N): X LUMP SUM PAYMENT AWARDED (Y/N): X
[9-C]
________________________ WILL BE DELETED FROM THIS PENSION - CONTINUE (Y/N): X
[10-O]
DATE PENSION AMOUNT WAS LAST VERIFIED (MMCCYY): 999999
[11-C]
FUTURE PENSION ENTITLEMENT DATE (MMCCYY): 999999
[12-M}
DELETE THIS GOVERNMENT PENSION (Y/N): P
[13-C]
THIS OCCURRENCE OF DATA WILL BE DELETED FROM CLIENT AND MBR-CONTINUE (Y/N):
X
PF1 HELP AVAILABLE
TRANSFER TO: XXXX

MCS
CLAIMANT MAILING ADDRESS
CADR
NH: SSSSSSSSS SSSSS SSSSSSSSSS
CL: SSSSSSSSS SSSSS SSSSSSSSSS
[1-M]
ADDRESS 1: PPPPPPPPPPPPPPPPPPPPPP
ADDRESS 2: PPPPPPPPPPPPPPPPPPPPPP
ADDRESS 3: PPPPPPPPPPPPPPPPPPPPPP
ADDRESS 4: PPPPPPPPPPPPPPPPPPPPPP
[2-M]
[3-C]
[4-C]
CITY: PPPPPPPPPPPPPPPPPPPPPP
STATE: PP
ZIP: PPPPP
[5-C]
[6-C]
STATE & COUNTY CODE: PPPPP
COUNTY: XXXXXXXXXXXXXX
[7-C]
[8-C]
COUNTRY: PPPPPPPPPPPPPPPPPPPPP
CONSULAR CODE: PPP
[9-C]
FOREIGN POSTAL ZONE: PPPPPPPPPPPPPPP
[10-C]
[11-C]
DIRECT DEPOSIT ROUTING TRANSIT NUMBER: 999999999
ACCOUNT TYPE (C/S): A
[12-C]
DEPOSITOR ACCOUNT NUMBER: 99999999999999999
[13-C]
[14-C]
DOMESTIC PHONE: PPPPPPPPPP
FOREIGN PHONE: PPPPPPPPPPPPPPP

TRANSFER TO: XXXX NH IDENTIFICATION
NHID
NH SSSSSSSSS SSSSS SSSSSSSSSS
CL SSSSSSSSS SSSSS SSSSSSSSSS
[1-M]
EVER MARRIED (Y/N): X
[2-M]
NH DEP CHILDREN (Y/N): X
[3-M]
NH DEP PARENTS (Y/N): X
[4-M]
WORK LAST YEAR OR THIS YEAR (Y/N): X
[5-M]
[6-M]
[7-M]
PRIOR APPLICATION FOR RSDI (Y/N): X FOR SSI (Y/N): X FOR MEDICARE (Y/N): X
[8-C]
[9-C]
CROSS REFERENCE SSN: 999999999 STAT: XX SSN: 999999999 STAT: XX
[10-C]
[11-C]
NH NAME IN PRIOR APPLICATION: XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX SSN: 999999999
NH NAME IN PRIOR APPLICATION: XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX SSN: 999999999
[12-C]
MULTIPLE SSN: 999999999 999999999 999999999 999999999 999999999
[13-C]
OTHER NAMES: XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XXXX
XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XXXX
XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XXXX
XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XXXX
XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XXXX

COMM
DEPENDENT CHILD IN CARE
DCIC
[2-D]
[3-D]
[1-D]
NH: SSSSSSSSS SSSSS SSSSSSSSSS BN: SSSSSSSSS SSSSS SSSSSSSSSS PIC: SSS
CHILD OF N H UNDER AGE 16 OR DISABLED IN PAST 13 MONTHS OR SINCE N H DEATH
[5-O]
[6-M]
[4-M]
*CHILD FIRST NAME: XXXXXXXXXXXXXXX MIDDLE: X *LAST: XXXXXXXXXXXXXXXXXXXX
[7-M]
[8-M]
[9-C]
*S S N CHILD ENTITLED ON: 999999999 *PIC: XX CHILD BOAN: 999999999
[10-M]
*MONTH CHILD IN CARE MET (MMCCYY): 999999
[11-C]
CHILD ENTITLED ON ANOTHER S S N, ENTER REASON, IF CHILD IN CARE ENDED: 9
1=CHILD ATTAINED AGE 16
4=CHILD MARRIED
2=CHILD DECEASED
5=CHILD TERMINATED/OTHER
3=CHILD NO LONGER DISABLED.
[12-C]
IF CHILD ENTITLED ON ANOTHER S S N, MONTH CHILD IN CARE ENDED (MMCCYY): 999999
[13-O]
REMARKS:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[14-O]
DELETE THIS OCCURRENCE OF DATA (Y/N): X
[16-O]
[15-O]
ADD NEW OCCURRENCE (Y/N): X
REVIEW PRIOR OCCURRENCES (Y/N): X
[17-D]
[18-O]
PF1 HELP AVAILABLE
TRANSFER TO: XXXX

MCS TRANSFER TO: XXXX INFORMATION ABOUT THE DECEASED
DECD
NH SSSSSSSSS
SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS SSSSSSSSSS
[1-M]
[2-M]
[3-C]
DATE OF DEATH: 99999999 PROOF (P/N): X TYPE OF PROOF (P/O): X
[4-M]
DOMICILE AT DEATH: XXXXXXXXXXXXXXX
[5-M]
PLACE OF DEATH (CITY/STATE): XXXXXXXXXXXXXXX
[6-M]
[7-C]
DISABLED AT TIME OF DEATH (Y/N): X
DISABILITY BEGAN: 999999
[8-C]
WAS CLAIMANT ELIGIBLE AS WIDOW(ER) PRIOR TO 1985 ON ANY SSN (Y/N): X
[9-C]
SURVIVING SPOUSE (Y/N): X
[10-C]
NAME: XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX
[11-C]
ADDRESS: XXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXX
[12-C]
SPOUSE LIVING WITH DECEASED AT TIME OF DEATH (Y/N): X
[13-C]
[14-C]
AWAY FROM HOME: 9
1. DECEASED
DATE LAST HOME: 999999
2. SPOUSE
[15-C]
REASON FOR SEPARATION AT DEATH:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[16-C]
IF DUE TO ILLNESS, NATURE OF ILLNESS:
XXXXXXXXXXXXXXXXXXXXXXXXXXX
[17-C]
REASON ABSENCE BEGAN:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[18-C]
IS SPOUSE: 9 1. LIVING IN SAME HOUSEHOLD 2. ELIGIBLE OR ENTITLED TO BENS
3. NOT ENTITLED TO LSDP

MCS TRANSFER TO: XXXX INFORMATION ABOUT THE DECEASED
DECD
NH SSSSSSSSS
SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS SSSSSSSSSS
[1-M]
[2-M]
[3-C]
DATE OF DEATH: 99999999 PROOF (P/N): X TYPE OF PROOF (P/O): X
[4-M]
DOMICILE AT DEATH: XXXXXXXXXXXXXXX
[5-M]
PLACE OF DEATH (CITY/STATE): XXXXXXXXXXXXXXX
[6-M]
[7-C]
DISABLED AT TIME OF DEATH (Y/N): X
DISABILITY BEGAN: 999999
[8-C]
WAS CLAIMANT ELIGIBLE AS WIDOW(ER) PRIOR TO 1985 ON ANY SSN (Y/N): X
[9-C]
SURVIVING SPOUSE (Y/N): X
[10-C]
NAME: XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX
[11-C]
ADDRESS: XXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXX
[12-C]
SPOUSE LIVING WITH DECEASED AT TIME OF DEATH (Y/N): X
[13-C]
[14-C]
AWAY FROM HOME: 9
1. DECEASED
DATE LAST HOME: 999999
2. SPOUSE
[15-C]
REASON FOR SEPARATION AT DEATH:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[16-C]
IF DUE TO ILLNESS, NATURE OF ILLNESS:
XXXXXXXXXXXXXXXXXXXXXXXXXXX
[17-C]
REASON ABSENCE BEGAN:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[18-C]
IS SPOUSE: 9 1. LIVING IN SAME HOUSEHOLD 2. ELIGIBLE OR ENTITLED TO BENS
3. NOT ENTITLED TO LSDP