You reported that you lost your (1) benefit check for $ (2) after you signed it. The Treasury Department told us this check has not been cashed, so we have stopped payment on it.

Since the original check has not been cashed, we are sending you a replacement check. If you find the original check, you should return it to your local Social Security office as soon as possible. If the original check is cashed, we will ask you to pay us back $ (3) .

If You Have Any Questions

3901C

OR

3765C

• •

  The PC or FO sends this notice when a beneficiary reports a lost check that has been signed.

• •

  Use paragraph 3901C on PC notices and 3765C on FO notices.

• •

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

• •

  Refer to NL 00703.765 for 3765C text and fill-ins.

   

Fill-ins:

1. (1) 

   Date of check (MM/DD/YY)

2. (2) 

   Amount of lost check

3. (3) 

   Amount of overpayment check (same as (2))