TN 30 (03-96)

Document Identifier for Word Processor: E3595

A. EXHIBIT LETTER

We are writing to tell you about an incorrect Social Security payment which you have received, and how you can pay this money back.

How The Incorrect Payment Happened

We deposited $ (1) into (2) bank account at (3) after (4) death on (5) . This money was not due (6) , because no check is due for the month of death or for later months. In this case, we did not learn about the death in time to stop the payment from being incorrectly deposited into the bank account.

We were unable to recover all of the incorrectly paid money from the joint account. Since you withdrew $ (7) from the account, you owe this amount to us.

How To Pay Us Back

You should send us a check or money order for $ (8) , the amount you withdrew from the bank account. Make your check or money order out to the Social Security Administration. Be sure to put the Social Security claim number, which is shown above, on the check or money order. Please use the enclosed envelope to mail it to us.

If You Have Any Questions

3901C

Enclosure:

Refund Envelope

B. REQUESTING INSTRUCTIONS

Use this letter to notify an individual that he/she should return incorrectly paid money that was withdrawn from a deceased beneficiary's bank account.

Fill-ins:

1. amount of incorrect deposit

2. full name of beneficiary, possessive

3. name of banking institution on TFS-133

4. his, her

5. date of beneficiary's death

6. him, her

7. amount of withdrawal

8. amount of withdrawal

Refer to NL 00703.005E. for 3901C text.