TN 30 (03-96)

Document Identifier for Word Processor: E3302

A. EXHIBIT LETTER

We need information from you to decide if you should still receive checks while you are outside the U.S.

Our records show you left the U.S. in (1) . When you live outside the U.S. for more than 6 months, you need to have your checks sent to your foreign address and you need to report certain events. For this reason, we need some information from you.

What You Need To Do

To help you give us the information we need, we have enclosed two forms. Please complete both forms and return them in the enclosed envelope. Be sure to put a stamp on the envelope.

If we do not receive the completed forms within 60 days of the date of this letter, we will stop your checks. We will send you another letter at that time with more information about our actions.

If You Have Any Questions

3901D

Enclosures:

Form SSA-21

SSA-7162-OCR-SM

Envelope

B. REQUESTING INSTRUCTIONS

• This letter is used to notify a beneficiary who has been living in a foreign country and having his/her benefit check mailed to a U.S. address that his/her benefits will be suspended if the Forms SSA-7162-OCR-SM and SSA-21 are not received within 60 days from the date of this notice.

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

   

Fill-in:

1. month/year

C. TYPING INSTRUCTIONS

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