TN 30 (03-96)

Document Identifier for Word Processor: E3705

A. EXHIBIT LETTER

We received your request for withdrawal of your application for (1) insurance benefits after we had disallowed the claim.

Since it does not appear that withdrawing the claim will be of any advantage to you, we are taking no further action on your request.

If you still wish to withdraw your claim or if you have any questions, you may call us toll-free at 1-800-772-1213, or call your local Social Security office at (FO telephone number). We can answer most questions over the phone. You can also write or visit any Social Security office. The office that serves your area is located at:

• District Office Address

  City, ST ZIP

If you do call or visit an office, please have this letter with you. It will help us answer you questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

B. REQUESTING INSTRUCTIONS

The claims authorizer will request this notice and provide the necessary fill-in.

Fill-in:

1. type of benefit