TN 34 (05-98)

NL 00703.821 Final Notice to the Former Representative Payee, or the Non-Selected Payee Applicant When Another Payee is Appointed

(See GN 00503.130)

Document Identifier for Word Processor: E3821

A. Exhibit Letter

We have decided that it would be best for (1) to have (2) (3) checks sent to another payee.

If going to the former representative payee, use:



If You Have Saved Any Money

While you were (1) representative payee, you may have saved some money for (2) . If you have, you should return it to us unless you have already made other plans with us for handling it. The money you will need to return includes:

  • Saved and invested benefits.

  • Interest earned from these savings and investments.

  • Money you have left over from any checks we sent you.

  • Any checks you might get after the date of this letter.

How To Pay Us Back

To do this, you can write us a check or money order. Make it out to the Social Security Administration. Be sure to write “Conserved Funds for (3) , (4) ” on that check or money order. Please mail it in the enclosed envelope.



What You Need To Do
As soon as possible, you should send us a final report of how you used the benefits you got. Use the “Representative Payee Report” we are sending you to do this. It tells you the period of time for which you have to report.


If You Have Any Questions

3901C - Domestic

3901D - Foreign

Enclosures (see requesting instructions for appropriate enclosure)

B. Requesting Instructions

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

For change of payee situations: Send this letter when the unsuccessful applicant is not the parent, person standing in place of the parent or legal guardian.



  1. (1) 

    full name of beneficiary

  2. (2) 

    his, her

  3. (3) 

    Social Security, Supplemental Security Income

  4. (4) 

    If paragraph 3821A is requested:


    Return envelope

    If paragraph 3821B is requested:


    Return envelope

    SSA-623-OCR-SM (for domestic cases) or SSA-7161-OCR-SM (for foreign cases)

    Use paragraph 3821A (“If You Have Saved Any Money” and “How To Pay Us Back” ) only if return of conserved funds is requested, i.e., to all former payees. Omit this paragraph when this letter is sent to an unsuccessful payee applicant.


  1. (1) 

    first name of beneficiary, possessive, in the format of John's, if child; if adult, “Mr.” or “Ms.” last name possessive in format Mr. Smith's

  2. (2) 

    him, her

  3. (3) 

    full name of beneficiary

  4. (4) 

    actual claim number (Title II cases) or Social Security number (Title XVI), as appropriate.

Add paragraph 3100FC as the second paragraph under the caption, “How To Pay Us Back,” if a foreign address is involved. See NL 00703.100 for text.

Use paragraph 3821B if a final accounting is requested.

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

C. Typing Instructions

In title II cases use Form SSA-L2000-C2 (Universal Notice) and follow the notice standards. Use the SSA-L8025-U2 (Supplemental Security Income Notice of Decision) or SSA-L8165-U2 (Supplemental Security Income Notice) as appropriate. Refer to NL 00801.015C.

To Link to this section - Use this URL:
NL 00703.821 - Final Notice to the Former Representative Payee, or the Non-Selected Payee Applicant When Another Payee is Appointed - 10/28/2005
Batch run: 04/25/2016