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.

3901C

 OR

3901D

In title II and Black Lung cases, the FO is responsible for designating the notice. The PC is responsible for all fill-ins. In title XVI cases, the FO is responsible for the entire notice.

 

Fill-ins:

1. (1) 

   name of Payee

2. (2) 

   Social Security, Supplemental Security Income, Black Lung

3. (3) 

   name of Payee

Select paragraph 3901D if the address is a foreign one. Otherwise, select paragraph 3901C.

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

In title II and Black Lung 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 Form SSA-L8025-U2 (Supplemental Security Income Payment Decision), or Form SSA-L8166-U2 (Supplemental Security Income Notice) as appropriate. Refer to NL 00801.015C.