We are writing to tell you about extra money we are sending you for (1) .

What We Will Pay and When

• •

  (2) is due $(3) from (4) through (5) .

• •

  You will get this money over a period of months.

• •

  We will send you $(6) each month in addition to the regular check you already get for them.

• •

  These checks will start (7) and end when all of the extra money is paid to you.

If You Have Any Questions

3901C - Domestic

3901D - Foreign

The FO sends this notice when accrued benefits were withheld at the time benefits were awarded and the withheld amount will now be paid to the representative payee in monthly installments.

Fill-ins:

1. (1) 

   Name of beneficiary in the format, Joan Sands

2. (2) 

   First and last name of beneficiary, if child or adult.

3. (3) 

   Total amount of money due the beneficiary

4. (4) 

   First month and year accrued benefits were withheld in the format, May 1992

5. (5) 

   Last month and year accrued benefits were withheld

6. (6) 

   Amount to be paid in each installment

7. (7) 

   Month, day, year the first installment payment will be made in the format of August 3, 1993.

Optional Paragraph 3350A:

1. (1) 

   Beneficiary first name, if child; if adult, “Mr.” or “Ms.” with last name

Use paragraph 3350A when the type of payee code (TYP) is not SLM.

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

Use FO Letterhead and follow the notice standards. Information for this notice will be shown on Form SSA-573.