TN 13 (06-09)

Use one of the following lead-in paragraphs:

4158 Auxiliary – Lead-In -- Allowance to Denial

We are writing to you about your Social Security benefits. We recently looked at (1) disability case again to make sure our decision was correct. After reviewing all of the information carefully, we are changing our decision. We now find that (2) was not disabled. Therefore, based on our rules, we are denying your claim for benefits. You will get another letter soon about when your payments will stop.

Fill-ins:

(1) number holder’s name (possessive)

(2) he/she

OR

4014 Auxiliary – Lead-In – Closed Period

We are writing to let you know that we recently reviewed __(1)__ disability case. After reviewing all of the information carefully, we have decided __(2)__ is no longer disabled. When __(3)__ payments stop, your benefits will also stop.

Fill-ins:

(1) number holder’s name (possessive)

(2) he/she

(3) his/her

ALS023

If You Disagree With The Decision

If you disagree with this decision, you have the right to appeal. We will review (1) case and consider any new facts you have. A person who did not make the first decision will decide (2) case. We will review those parts of the decision which you believe are wrong and will look at any new facts you have. We may also review those parts which you believe are correct and may make them unfavorable or less favorable to (3) .

• You have 60 days to ask for an appeal in writing.

• The 60 days start the day after you get this letter. We assume you got this letter 5 days after the date on it unless you show us that you did not get it within the 5-day period.

• You must have a good reason for waiting more than 60 days to ask for an appeal.

• You have to ask for an appeal in writing. We will ask you to complete a Form SSA-561-U2, called “Request for Reconsideration.” Contact one of our offices if you want help.

Fill-ins:

(1) your/ number holder’s name (possessive)

(2) your/his/her

(3) you/him/her

Please read the enclosed pamphlet, “Your Right to Question the Decision Made on Your Claim.” It contains more information about the appeal.

Do not send the following caption and paragraph (4060) if there is a determination of fraud or similar fault (FSF), since FSF precludes the payment of statutory benefit continuation. Do not send the following caption and paragraph if the revision is due to a non-medical reason, such as work, or other reason that precludes statutory benefit continuation (SBC) payments (see DI 27540.025). However, a predetermination due process notice is needed.

4060 Statutory Benefit Continuation – Auxiliary

Contact Us In 10 Days To Keep Getting Your Payment

Please let us know if you would like us to continue your benefits during your appeal. You have only 10 days to ask us in writing to continue your benefits.

Both you and (1) must ask for your payments to continue, and either you or (2) must file an appeal.

If the appeal is lost, you might have to pay back some or all of the money you got.

Fill-ins:

(1) number holder’s name

(2) number holder’s name

4069A

If You Want Help With Your Appeal

You can have a friend, representative, or someone else help you. There are groups that can help you find a representative or give you free legal services if you qualify. There also are representatives who do not charge unless you win your appeal. Your local Social Security office has a list of groups that can help you with your appeal.

If you get someone to help you, please let us know. If you hire someone, we must approve the fee before he or she can collect it. If you hire a representative who is eligible for direct pay, we will withhold up to 25 percent of any past-due benefits to pay toward the fee.

4078

If You Have Any Questions

If you have any questions, please call us toll free at 1-800-772-1213, or call your local Social Security office at [FO phone number from DOORS]. 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:

Fill-in:

               [Field Office Address

                City, State, ZIP] per DOORS

If you do call or visit an office, please have this letter with you. It will help us answer your 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.

Enclosure:

SSA Pub. No. 05-10058