We have decided that it would be best for you if (1) continues to be your representative payee. This means that your (2) checks will still be paid to (3) to use for your needs.

Do You Disagree With The Decision?

If you think you should get your own checks or that someone else should help you manage your checks, you have the right to appeal. We will review your case again and consider any new facts you have. (4) Then a person who did not make the first decision will decide your case again.

• •

  You have 60 days to ask for an appeal.

• •

  The 60 days start the day after you get 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.¹

• •

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

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  To appeal, you must fill out a form called “Request for Reconsideration.” The form number is SSA-561-U2. To get this form, contact one of our offices. We can help you fill out the form.

If You Have Any Questions

3901C - Domestic

3901D - Foreign

Enclosure:

Pamphlet No. SSA-05-10058

¹ Delete this sentence for foreign cases.

In title II cases, the PC should send the notice when the legally competent adult beneficiary requests direct payment but the decision is to continue to pay his/her benefits to the payee of record. In title XVI cases the FO is responsible for preparing and releasing this notice.

Fill-ins:

1. (1) 

   name of payee

2. (2) 

   Social Security, Supplemental Security Income, Black Lung

3. (3) 

   him, her, them

4. (4) 

   Include this sentence only in title II cases.

Select paragraph 3822D (“How To Appeal”) and 3215E (“If You Want Help With Your Appeal”) in title XVI cases.

See NL 00703.005E. for 3901C and 3901D text and fill-in.

See NL 00703.215 for 3215E text.

In title II cases use Form SSA-L2000-C2 (Universal Notice) and follow the notice standards. Information for this notice will be on the Form SSA-573. In title XVI cases, use the SSA-L8025-U2 (Supplemental Security Income Payment Decision), or Form SSA-L8166-U2 (Supplemental Security Income Notice) as appropriate. Refer to NL 00801.015C.