NL: Notices, Letters and Paragraphs
A. Sample form
B. Preparation of form
The source of information for completing the name and address is Form SSA-3428-U2, Determination of Disallowance Coding Sheet.
If a representative payee is involved, add the word “for” after benefits in the first sentence and include the name of the beneficiary. If more than one child beneficiary is involved each child will need a separate notice.
This notice does not require any fill-ins.