TN 30 (03-96)

NL 00703.122 Advance Notice - Benefits Will Be Stopped

Document Identifier for Word Processor: E3122

A. Exhibit Letter

We are writing to tell you that we plan to stop your checks (1) as of (2) because we were told that (3) .


If You Disagree With The Decision

Please tell us within 101 days of the date of this letter if you disagree with the decision. You will also need to give us any proof you have to show that what we were told is wrong.

If you let us know within 101 days that you disagree with the decision, we will not stop your checks. We will continue to pay you while we review your case to see if you are right. However, if you are wrong we will ask you to pay back any money you received that was not due.

If we do not hear from you within 101 days, we will stop your checks. We will send you another letter at that time with more information about our action.


If You Have Any Questions

3901C - Domestic

3901D - Foreign

B. Requesting Instructions

  • The person who determines that benefits will be suspended or terminated is responsible for requesting this notice and providing the appropriate fill-ins. The notice should be requested on an SSA-573 and all fill-ins listed. Refer to GN 03001.000.




  1. a. 

    if other family members are involved, then: “and those of your family”

  2. b. 

    otherwise, null


month/year of termination/suspension


reason for action, for example: “you were divorced on (month/day/year)” or “you were married on (month/day/year)”

  • Refer to NL 00703.005E for 3901C and 3901D text and fill-ins.

C. Typing Instructions

FO's will use standard FO letterhead. If the PC is involved, use Form SSA-L2000-C2 (Universal Notice) and follow the notice standards. Information for this notice will be shown on Form SSA-573.


1 For foreign beneficiaries, 30 days.

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NL 00703.122 - Advance Notice - Benefits Will Be Stopped - 12/24/2003
Batch run: 07/08/2013