TN 106 (11-23)

NL 00703.128 Advance Adverse Adjustment — Only Past Due Benefits Affected

Document Identifier for Word Processor: E3128

A. Exhibit Letter

We are writing to tell you that we plan to reduce (1) past Social Security benefits (2) because (3) filed for benefits as the (4) of (5) . Here is what we were given as proof:



We plan to pay benefits to (7) . When we do this, we will reduce the benefits you received. This is because we have a limit on how much we can pay on each person's Social Security record.


If You Disagree With The Decision


Please tell us within (8) days of the date of this letter if you disagree with the decision. You will also need to give us any proof that (9) benefits should not be reduced.

If you let us know within (10) days that you disagree with the decision, we will not reduce (11) past benefits. We will review the 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 (12) days, we will reduce (13) past benefits. We will send you another letter at that time with more information about our action.


If You Have Any Questions


3901C - Domestic

3901D - Foreign

*For foreign beneficiaries, use 30 days.

B. Requesting Instructions

Any previously-entitled beneficiary whose past benefits (outside of a protected period) will be adversely affected must also receive an advance due process notice. This also applies when the currently-entitled beneficiary's ongoing rate is not affected by a late-filer but their past benefits will be reduced. However, since no current benefits are affected, the advance adverse adjustment notice in NL 00703.120 is not appropriate.


  1. (1) 

    your, beneficiary's full name (possessive case)

  2. (2) 

    if the beneficiary was receiving benefits directly and was also representative payee for others whose benefits may be affected, then: “and the benefits you received for [name(s) of other beneficiaries. ]” (Otherwise, null.)

  3. (3) 

    name of new claimant (if an adopted child living in another household, do not show new adoptive name. Instead, show the child's first name and age).

  4. (4) 

    relationship of new claimant to NH (e.g., spouse, child, etc.).

  5. (5) 

    name of NH.

  6. (6) 

    explanation of evidence (paragraph should be indented 3 spaces from last margin.

  7. (7) 

    first name of new claimant [see fill-in (3)].

  8. (8) 

    10 (domestic)/30 (foreign)

  9. (9) 

    your, beneficiary's full name (possessive case).

  10. (10) 

    10 (domestic)/30 (foreign)

  11. (11) 

    your, beneficiary's full name (possessive case).

  12. (12) 

    10 (domestic)/30 (foreign)

  13. (13) 

    your, beneficiary's full name (possessive case).

Refer to NL 00703.005E for 3901C text.

C. Typing Instructions

Follow the notice standards. Because the requested fill-ins and paragraphs may vary according to different situations, follow the requester's instructions carefully.

To Link to this section - Use this URL:
NL 00703.128 - Advance Adverse Adjustment — Only Past Due Benefits Affected - 11/20/2023
Batch run: 01/30/2024