Form SSA-832-C3/U3 Cessation or Continuance of Disability or Blindness Dete

Form Approved
OMB No. 0960-0443

TITLE XVI
1. A. SOCIAL SECURITY NUMBER

Social Security Administration

CESSATION OR CONTINUANCE OF DISABILITY
OR BLINDNESS DETERMINATION AND TRANSMITTAL

-

-

No further monies or other benefits may be paid out under this program unless this report is completed and filed as required by existing public law 93-233.

1. B. TYPE CLAIM
DI

DS

DC

BI

BS

1. C. OTHER ENTITLEMENT
TITLE II

BC

2. A. NAME OF PAYEE (IF ANY)
B. NAME OF DISABLED OR BLIND INDIVIDUAL

4. DATE OF BIRTH

3. ADDRESS

6. DO ADDRESS

8.

A.

INITIAL

5. DATE DISABILITY BEGAN

B.

RECON

C.

RECON
DHU

ALJ
HEARING

D.

9. UPON CONSIDERATION OF ALL FACTS, IT IS DETERMINED:

A. CONTINUES
DA AND A
DOES
CONTRIBUTE TO FINDING

DOES NOT

APPEALS
COUNCIL

E.

7.DO CODE

F.

U.S. DISTRICT
COURT
G.

DDS CODE

REOPENING

DISABILITY
I. 301 CASE
J. BLINDNESS
(1)CONTINUES

MONTH, DAY, YEAR

MONTH, DAY, YEAR

B. CEASED
BEGAN

STATE PLAN LAST MET
C. ELIGIBILITY TERMINATED AT THE
CLOSE OF THE LAST DAY OF

(2)CEASED
(3)CEASED
OTHER IMPAIRMENT BEGAN

10. BASIS FOR DETERMINATION
MEDICAL/MEDICAL VOC.
A.

B.

WORK - NO IRWE

11. REASON FOR CESSATION

CODE:

13.

14.

CHECK IF ATTACHING A
CONTINUATION SHEET.

15. VOCATIONAL BACKGROUND

C.

WORK - IRWE INVOLVED D.

12. REASON FOR
CONTINUANCE
CHECK IF VOCATIONAL
RULE MET.
16. OCC. YEARS

19. VR ACTION.

A.

OTHER (Explain in item 24.)

CODE:

MEDICAL LIST NO.

CITE RULE
17. EDUC. YEARS 18. SPECIAL USE
20. WHY REVIEW WAS MADE - CODE:

SC IN

21. PRIMARY DIAGNOSIS:

PREV. REF.
RE-REF
D.
CODE
NO.
BODY SYSTEM
22. SECONDARY DIAGNOSIS:

B.

SC OUT

C.

CODE NO.

23. DIARY
A.
TYPE

B.
MONTH

YEAR

C.
REASON

MULTIPLE IMPAIRMENTS CONSIDERED

24. REMARKS

24.A. COMBINED MULTIPLE
NONSEVERE-SEVERE
24.B. COMBINED MULTIPLE
NONSEVERE-NONSEVERE
27.PHYSICIAN OR MEDICAL SPEC. SIGNATURE 28. DATE

25. DISABILITY EXAMINER/CLAIMS REP.

26. DATE

29. LETTER/PARAGRAPH NUMBER

30. PHYSICIAN OR MEDICAL SPEC. NAME (STAMP, PRINT, OR TYP30.A. SPEC. CODE

31. SSA REPRESENTATIVE
A.

B.

C.

D.

34. LIST
NUMBER

FORM

SSA-832-C3/U3 (5-1989) ef (10-2004)

E.

F.

32. SSA CODE 33. DATE

35. FOLDER SENT TO

3 Copies: (Folder, VR, State Agency/Data)

PRIVACY ACT/PAPERWORK ACT NOTICE
We are authorized to collect the information under Sections 221(a) and (b) of the Social Security Act
and Section 416.1015(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 claimant's 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 do 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 questions unless we display a valid Office of Management and Budget control number.
We estimate that it will take about 30 minutes to read the instructions, gather the facts, and answer the
questions. You may send comments on our time estimate above to: SSA, 1338 Annex Building,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not
the completed form.