TN 54 (06-09)

(RS 00207.025)

Document Identifier for Word Processor (AURORA): E3932 and E3932.1

A. Exhibit letter - Benefits suspended due to number holder’s death

(1)

We are writing to let you know that we have made some changes in your benefits. These changes are based on the death of (2) in (3) .

Changes in your benefits

• You are no longer entitled to (4) benefits. We have stopped your (5) benefits starting in (6) .

• You will still get retirement or disability benefits on your own record.

• You may be able to get permanently reduced (7) benefits. The benefit rate is reduced by a specified percentage for each month you are entitled before full retirement age (FRA). For example, if you were born between 1945 and 1956, the benefit reduction would be about 0.396 percent for each month you are entitled before your FRA. If the deceased worker received retirement benefits before FRA, the maximum survivor’s benefit is limited to the higher amount that the deceased worker would have received if still alive or 82.5 percent of the deceased worker’s unreduced benefit.

  Because of this limit, delaying receipt of reduced (8) benefits will not necessarily increase the monthly benefit amount payable. We will review your election in item 3 on the Certificate of Election to make sure that the month selected maximizes your benefit amount.

• If you wish to receive permanently reduced benefits, please complete the (9) and return it to us in the self-addressed envelope provided. If you need help completing the certificate, your local Social Security office will be happy to help you.

   

  What we will pay and when

  • Your regular monthly benefit is $ (10) , beginning (11) . This is the benefit due you based on your own Social Security record. Your Social Security number is (12) .

  • You should receive your first check about (13) . After that you will get your regular check about the (14) of each month.

   

  Other Social Security benefits

  • If the deceased worker’s death occurred prior to FRA or prior to one year past FRA and he/she could not work due to disability before death, you may be able to get higher benefits on the deceased worker’s record. You have to file a separate application for the higher benefits within 3 months after the month the worker died.

  • If you were married before, you may be able to get a higher benefit on your prior spouse’s record. Please file an application to determine if you are eligible for these benefits.

  If you disagree with the decision ¹

  ALS020

  If you want help with your appeal²

  3100E

   If you have any questions

  3901C - (CTDO UTI) - Domestic

  3901D - Foreign

  Enclosures³ :

  SSA-4111

  Self-addressed Envelope

B. Procedure requesting instructions

• Send this exhibit notice when the spouse or divorced spouse of an under full retirement age dually entitled beneficiary dies, spouse's (divorced spouse’s) benefits are suspended, and the surviving spouse (or surviving divorced spouse) may be entitled to reduced widow's or widower's (or surviving divorced spouse’s) benefits.

• See NL 00703.005E for 3901C and 3901D text and fill-in. Use ALS020 in domestic and foreign cases. Refer to NL 00703.180 for ALS020 text. Refer to NL 00703.100 for 3100E text.

  NOTE: AURORA UTI in lieu of 3901C is UTI CTDO. See Language Development Facility (LDF) for text.

Fill-ins:

(1) We are sorry to learn of your loss. Please accept our sincere sympathy.

(Request fill-in (1) if notice is for widow(er))

(2) first and last name of deceased worker

(3) month/year of death; e.g., July 1993

(4) wife's/husband's or divorced spouse’s

(5) wife's/husband's or divorced spouse’s

(6) month/year

(7) widow's/widower's or surviving divorced spouse’s

(8) widow’s/widower’s or surviving divorced spouse’s

(10) payable retirement benefit

(11) month/year of change

(12) beneficiary's Social Security number

(13) Month, day, year, e.g., August 3, 2004

(14) A = 3rd
       B= 2nd Wednesday
       C= 3rd Wednesday
      D= 4th Wednesday

C. Procedure instructions for SSA L 2000 (Universal Notice)

Use Form SSA-L2000-C2 (Universal Notice) and follow the notice standards. See NL 00703.005E for 3901C and 3901D text. Refer to LDF for UTI CTDO text.

Footnotes:

[1]

If there is an overpayment, omit this paragraph.

[2]

If the person lives outside the U.S. or has an attorney, omit this paragraph.

[3]

Omit this enclosure if the TSC or FO sent the certificate.