To authorize supplemental mercury benefits, complete a blank Form 552 as follows:

  • Item 1 - Complete.
  • Item 2 - Enter the month and year (4 digits) that the increase was effective.
  • Item 3 - Enter TA 31.
  • Item 4 - Enter 2.
  • Items 5, 6 - Complete.
  • Items 8-10 - Enter the name and address as it currently exists in the Client Database.
    • NOTE: If the name or address has recently changed, the change must be made on the regular roll before the mercury request is authorized to the new name or address.
  • Item 38 - Enter the total amount of supplemental benefits for the month entered in Item 2.
  • Item 80 - Complete. The total of amounts entered in Item 80 must equal the amount entered in Item 38.