TN 30 (03-96)

(GN 00503.100)

Document Identifier for Word Processor: E3767

DPS

A. EXHIBIT LETTER

We are completing our work on your application for Social Security benefits. This letter is about how we will pay you if we decide that you can receive benefits. We will send you another letter when we finish our work on your application.

How We Plan To Pay You

The information we have shows that you need help managing your money and meeting your daily needs. Because of this information, we plan to send your benefits to (1) . We will call this (2) your representative payee.

Your Representative Payee's Duties

It is your representative payee's duty to manage your Social Security money. The representative payee must report changes that can affect your benefits and act in your best interest. We will ask your representative payee to show us how the money was used for you.

If You Disagree With This Decision

If you think you should get your own benefits or that someone else should help you manage your benefits, you have the right to appeal. You have the right to review the facts in your file. You can give us more facts to add to your file. We will review your case and consider any new facts you have. Then, a person who didn't make the first decision will decide your case.

• You have 60 days to ask for an appeal. However, unless we hear from you within 10 days, we will select the representative payee named above.

• The 10 days and 60 days start the day after you receive this letter. We assume you got this letter 5 days after the date on it unless you show us that you did not get it within the 5-day period.

• You must have a good reason for waiting more than 60 days to ask for an appeal.

• You have to ask for an appeal in writing. We will ask you to fill out Form SSA-561-U2, called “Request for Reconsideration.” To get this form, contact one of our offices. We can help you fill out the form.

   

If You Want Help With Your Appeal

3215E

If You Have Any Questions

3763A

OR

3901C

B. REQUESTING INSTRUCTIONS

The FO (or, on rare occasions, the PSC) sends this to a competent adult beneficiary or emancipated minor.

This notice should not be sent until the determination of entitlement is made.

Fill-ins:

1. Name of representative payee

2. person/organization

When a beneficiary files for more than one type of benefit and the claims are not awarded at the same time, separate advance notices must be sent. If adjudicated simultaneously, a dictated paragraph may be added so that one notice is released.

If an application has been filed by the officer of an institution, or entity, show the title of the officer and the name of the institution or entity. Do not show the name of such officer.

Use 3763A if the notice is sent by the FO. Use 3901C if the notice is sent by the PSC. Refer to NL 00703.215 for 3215E text. Refer to NL 00703.005E. for 3901C text. Refer to NL 00703.763 for 3763A text and fill-ins.

C. TYPING INSTRUCTIONS

This notice will usually be sent by the FO. It may be reproduced on FO letterhead. On the rare occasions when the PSC sends the letter, use Form SSA-L2000-C2 (Universal Notice) and follow the new notice standards. Information for this notice will be shown on Form SSA-573.