TN 30 (03-96)

Document Identifier for Word Processor: E3121

A. Exhibit Letter

We are writing to tell you that we plan to stop (1) Social Security checks (2) as of (3) because (4) filed for benefits as the (5) of (6) . Here is what we were given as proof:

(7)

We plan to pay benefits to (8) . When we do this, we will stop your benefits.

If You Disagree With The Decision

Please tell us within 30 days of the date of this letter if you disagree with the decision. You will also need to give us any proof that your benefits should not be stopped.

If you let us know within 30 days that you disagree with the decision, we will not stop your checks. We will continue to pay you while we review the case to see if you are right. However, if you are wrong we will ask you to pay back any money you received that was not due.

If we do not hear from you within 30 days, we will stop your checks. We will send you another letter at that time with more information about our action.

If You Have Any Questions

3901C - Domestic
3901D - Foreign

B. Requesting Instructions

• The person who determines that the beneficiary's(ies') benefits should terminate (generally the claims authorizer) is responsible for requesting this notice and providing the fill-ins.

   

Fill-ins:

1. your, or Name of Beneficiary (possessive case)

2. if the beneficiary is receiving benefits directly and is also representative payee for others whose benefits
   may be affected, then: “and the check you receive for (name(s) of other beneficiaries).” (Otherwise null)

3. month/year change is effective

4. name of new claimant

5. relationship of new claimant to Number Holder, e.g. wife, child, etc.

6. name of Number Holder

7. explanation of evidence (paragraph should be indented 3 spaces from left margin)

8. name of new claimant

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

C. Typing Instructions

Use Form SSA-L2000-C2 (Universal Notice) and follow notice standards. Information for this notice will be shown on Form SSA-573.