TN 14 (04-11)

                                                                                             **BARCODE**

AGENCY
LETTERHEAD

                                                                           Date: _______________

                                                                          Case ID: ____________

Addressee Name

Address Line 1

Address Line 2

City, State, Zip code

Dear (Mr. or Ms.) (Last name):

We are the office that makes disability decisions for the Social Security Administration. We need to speak with you within 10 days of the date on this letter about the matter below:

(List matter(s) here)

Please call the phone number shown below from Monday – Friday between

8:00 a.m. and 4:00 pm. If you do not respond by (date), we may decide your case based on the information we already have. This means that we could find that you are not disabled or that your disability has ended if you are already getting benefits.

Thank you for your help.

(Name)

Disability Examiner

(XXX) XXX-XXX

Toll Free: 1-800-XXX-XXXX, extension XXXX

cc: