We have chosen (1) to be your representative payee. Your payee will get your checks each month and will use this money for your needs.

If You Have Any Questions

3901C - Domestic

3901D - Foreign

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  Send to any legally incompetent adult for whom a payee is being appointed, or to a child under age 18 who has been receiving his/her own benefits but will now have a representative payee. In title II and Black Lung cases the FO is responsible for designating the notice; the PC is responsible for preparing and releasing the notice and providing the fill-ins. In title XVI cases, the FO is responsible for preparing and releasing the notice.

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

   

Fill-in:

1. (1) 

   name of new payee

In title II and Black Lung cases use Form SSA-L2000-C2 (Universal Notice) and follow the notice standards. Information for this notice will be on the SSA-573. In title XVI cases, refer to NL 00801.015C.

Use the SSA-L8025-U2 (Supplemental Security Income Payment Decision), or SSA-L8166-U2 (Supplemental Security Income Notice) as appropriate.