TN 30 (03-96)

Document Identifier for Word Processor: E3511

A. Exhibit Letter

We are writing to tell you that we plan to (1) (2) Social Security benefits because we learned that (3) (4) (5) payments. Based on information we have, we should have (6) the Social Security benefits beginning (7) .

The Information We Have

We have records that show the following information about (8) (9) payments:

What You Can Do

Please let us know right away if any of this information is wrong. We cannot use this information to change Social Security benefits until we give you time to check it. You will also need to give us any proof you have that shows that our information is wrong.

If We Do Not Hear From You

If we do not hear from you within (14) days from the date of this letter, we will assume the information in this letter is correct and use it to (15) (16) Social Security benefits.

We will send another letter at that time. It will explain the change in (17) benefits, the amount of any overpayment, and how to appeal our decision.

• You will have 60 days to ask for an appeal.

• The 60 days will start the day after you receive the next letter.

   

If You Have Any Questions

3901C

B. REQUESTING INSTRUCTIONS

Refer to NL 00703.005E. for 3901C text and fill-ins.

Fill-ins:

1. reduce/withhold

2. your/full name of disabled worker, possessive (in format; “Barry Smith's”

3. you/he/she

4. receive/receives/received an increase in

5. workers' compensation/public disability/black lung/federal employees compensation

6. reduced/withheld

7. month and year that offset should have begun or changed (in format; “June 1989”)

8. your/disabled worker's title and surname, possessive (in format; “Mr. Smith's” )

9. (Same as 5.)

10. amount(s) of WC, PDB, FECA or BL payments

11. effective month(s) and year(s) of WC, PDB, FECA or BL payments (in format; “June 1989”)

12. If the disabled worker is receiving PDB and initial offset is being applied, then add: “Less than 85 percent of the work used to figure (your/ his/her) public disability benefit was covered under Social Security. Because of this, we must (reduce/withhold) (your/his/her) Social Security disability benefits.”

13. If we received the information based upon a computer match, add the following sentence:

    We received this information when we matched computer records with the (name of organization paying the benefit, in format; “Department of Labor).”

14. 30 (if computer match)/10 (if other third party report)

15. (Same as 1.)

16. (Same as 8.)

17. your/his/her