TN 44 (12-04)

Document Identifier for Word Processor: E3213

DPS

A. EXHIBIT LETTER

We are writing to give you new information about (1) benefits that were misused by (2) former representative payee, _(3)_.

In _(4)_ , we notified you of our determination that _(5)_ misused (6) (7) benefits. We have determined that (8) due $ _(9)_. This amount represents the total amount of misused benefits minus any money that (10) has already repaid.

NEW SOCIAL SECURITY LAW

The Social Security law allows the Social Security Administration to reissue Social Security, Supplemental Security Income, and Special Veteran’s benefits whenever we or a court of competent jurisdiction find that an individual representative payee serving 15 or more beneficiaries, or an organizational representative payee, misused a beneficiary's payments. Under this authority, we will send (11) a check in the amount of $ (12). This check represents the amount due (13) as a result of (14) misuse, after subtracting any money that (15) has already repaid. You should receive this payment within 30 days.

IF YOU RECEIVE SSI PAYMENTS:

We will exclude these reissued benefits from resources under SSI for 9 months after the month in which you receive them.

IF YOU HAVE ANY QUESTIONS

If you have any questions, you may call us toll-free at 1-800-772-1213 or call your local Social Security Office at (16). 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:

(17)

 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 when you arrive at the office.

B. REQUESTING INSTRUCTIONS

Send this notice when SSA repays misused benefits to the beneficiary/new payee.

Fill-ins:

1. your / beneficiary’s full name, possessive

2. your / his / her

3. Name of misuser (former payee)

4. Date of Advanced Overpayment Notice to former payee and Cover letter to beneficiary/new payee

5. Name of misuser (former payee)

6. your / beneficiary’s full name, possessive

7. Social Security, Supplemental Security Income, Social Security and Supplemental Security Income, Special Veterans’ Benefits

8. you are / beneficiary’s full name is

9. Amount of misused benefits being repaid to beneficiary/new payee

10. Name of misuser (former payee)

11. you / beneficiary’s full name

12. Amount of misused benefits being repaid to beneficiary/new payee

13. you / beneficiary’s full name

14. Name of misuser (former payee), possessive

15. Name of misuser (former payee)

16. Phone number of local Social Security office

17. Address of local Social Security office