Form SSA-833-C3/U3 Cessation or Continuance of Disability or Blindness Dete

Form Approved
OMB No. 0960-0442

TITLE II

Social Security Administration

1. A. SOCIAL SECURITY NUMBER

CESSATION OR CONTINUANCE OF DISABILITY
OR BLINDNESS DETERMINATION AND TRANSMITTAL

-

BIC

-

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
DIB
FZ

CDB

DWB
2. A. NAME OF PAYEE (IF ANY)

1. C. OTHER ENTITLEMENT
TITLE II

HIB

ESRD

4. DATE OF BIRTH

B. NAME OF DISABLED OR BLIND INDIVIDUAL
C. ADDRESS

8.

A.

TITLE XVI

3. WE'S NAME (IF CDB OR DWB CLAIM)

5. DATE DISABILITY BEGAN
7.DO CODE

6. DO ADDRESS

INITIAL

B.

RECON

C.

RECON
DHU

ALJ
HEARING

D.

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

A. CONTINUES

E.

APPEALS
COUNCIL

DISABILITY

F.

U.S. DISTRICT
COURT
G.

DDS CODE

REOPENING

IMPAIRMENT SEVERITY
(EPE MEDICAL REVIEW ONLY)
I. 301 CASE
J. BLINDNESS

MONTH, DAY, YEAR

B. CEASED

MONTH, DAY, YEAR

(1)CONTINUES
C. PERIOD OF DISABILITY TERMINATED
AT THE CLOSE OF THE LAST DAY OF

BEGAN

D. EPE BEGIN MONTH
(a)DISABLED FOR CASH
PURPOSES

E. EPE REINSTATEMENT ALLOWED

(b)NOT DISABLED FOR CASH
BENEFITS PURPOSES SINCE

F. EPE REINSTATEMENT DENIED

(2)CEASED

G. EPE SUSP. AFTER REINSTATEMENT

(3) CEASED

H. EPE BENEFIT TERMINATION MONTH
10. BASIS FOR DETERMINATION
MEDICAL/MEDICAL VOC.
A.

OTHER IMPAIRMENT BEGAN

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 OUT C.
PREV. REF.
RE-REF
D.
BODY
SYSTEM
CODE
NO.
21. PRIMARY DIAGNOSIS:
22. SECONDARY DIAGNOSIS:
SC IN

B.

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 TYPE)

31. SSA REPRESENTATIVE

34. LIST
NUMBER

FORM

A.

B.

C.

D.

SSA-833-C3/U3 (5-1989) ef (3-2005)

E.

F.

30.A. SPEC. CODE

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 416.1615(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.
See Revised PRA Attached
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. Send only comments on our time estimate above to: SSA, 1338 Annex Building,
Baltimore, MD 21235-6401.

The following revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
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. 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 (TTY 1-800-325-0778).
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.