BENC05 – CAPTION
         You May Choose Not To Receive Benefits Right Now
         BENC06 – CAPTIONS
         Social Security Benefits Can Affect SSI Payments
         BENH01 – REFER TO WORKSHEET HEADER NL 00730.149C
         BEN008 – EXPLAINS VOLUNTARY DELAYED RETIREMENT CREDITS (DRC) TO THE BENEFICIARY
         (1) may choose to delay benefits on (2) own Social Security number beginning (3).
            Social Security benefits increase by a certain percentage if (4) retirement. We call
            this a delayed retirement credit. (5) can earn a credit for each full month after
            age (6) that (7) not receive a monthly benefit. (8) can earn credits for any months
            before age 70.
         
         While we cannot give financial advice, we can point out some things to consider. For
            example, (9) may want to consider:
         
         
            - 
               
                  • 
                     How (10) monthly benefit amount in the future would compare with (11) monthly benefit
                        amount today;
                      
 
 
- 
               
                  • 
                     How long it will take for future higher benefits to make up for benefits (12) not
                        to receive now; and
                      
 
 
- 
               
                  • 
                     The effect that Social Security benefits may have on (13) income taxes or private
                        pension(s).
                      
 
 
Please go to our Internet website at www.socialsecurity.gov for more information about delayed retirement credits. At this website, you can find
            out how much (14) benefit may increase.
         
         Please contact us right away if (15) would like to earn these delayed retirement credits
            instead of receiving benefits. Please use the telephone number or address shown below.
         
         If (16) to earn these credits and later (17) mind, just contact us and we will start
            (18) monthly retirement benefits.
         
         
            
               
               
                  
                  
                     
                     | Fill-in values: |   | 
               
               
                  
                  
                     
                     | Fill-in (1) |   | 
                  
                     
                     | Choice 1 | Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) | 
                  
                     
                     | Choice 2 | You | 
                  
                     
                     | Fill-in (2) |   | 
                  
                     
                     | Choice 1 | his | 
                  
                     
                     | Choice 2 | her | 
                  
                     
                     | Choice 3 | your | 
                  
                     
                     | Fill-in (3) | Full Retirement Age (FRA) attainment month and year in the format Month CCYY | 
                  
                     
                     | Fill-in (4) |   | 
                  
                     
                     | Choice 1 | he delays | 
                  
                     
                     | Choice 2 | she delays | 
                  
                     
                     | Choice 3 | you delay | 
                  
                     
                     | Fill-in (5) |   | 
                  
                     
                     | Choice 1 | He | 
                  
                     
                     | Choice 2 | She | 
                  
                     
                     | Choice 3 | You | 
                  
                     
                     | Fill-in (6) |   | 
                  
                     
                     | Choice 1 | 65 | 
                  
                     
                     | Choice 2 | 65 and 2 months | 
                  
                     
                     | Choice 3 | 65 and 4 months | 
                  
                     
                     | Choice 4 | 65 and 6 months | 
                  
                     
                     | Choice 5 | 65 and 8 months | 
                  
                     
                     | Choice 6 | 65 and 10 months | 
                  
                     
                     | Choice 7 | 66 | 
                  
                     
                     | Choice 8 | 66 and 2 months | 
                  
                     
                     | Choice 9 | 66 and 4 months | 
                  
                     
                     | Choice 10 | 66 and 6 months | 
                  
                     
                     | Choice 11 | 66 and 8 months | 
                  
                     
                     | Choice 12 | 66 and 10 months | 
                  
                     
                     | Choice 13 | 67 | 
                  
                     
                     | Fill-in (7) |   | 
                  
                     
                     | Choice 1 | he does | 
                  
                     
                     | Choice 2 | she does | 
                  
                     
                     | Choice 3 | you do | 
                  
                     
                     | Fill-in (8) |   | 
                  
                     
                     | Choice 1 | He | 
                  
                     
                     | Choice 2 | She | 
                  
                     
                     | Choice 3 | You | 
                  
                     
                     | Fill-in (9) |   | 
                  
                     
                     | Choice 1 | Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) | 
                  
                     
                     | Choice 2 | you | 
                  
                     
                     | Fill-in (10) |   | 
                  
                     
                     | Choice 1 | his | 
                  
                     
                     | Choice 2 | her | 
                  
                     
                     | Choice 3 | your | 
                  
                     
                     | Fill-in (11) |   | 
                  
                     
                     | Choice 1 | his | 
                  
                     
                     | Choice 2 | her | 
                  
                     
                     | Choice 3 | your | 
                  
                     
                     | Fill-in (12) |   | 
                  
                     
                     | Choice 1 | he chooses | 
                  
                     
                     | Choice 2 | she chooses | 
                  
                     
                     | Choice 3 | you choose | 
                  
                     
                     | Fill-in (13) |   | 
                  
                     
                     | Choice 1 | his | 
                  
                     
                     | Choice 2 | her | 
                  
                     
                     | Choice 3 | your | 
                  
                     
                     | Fill-in (14) |   | 
                  
                     
                     | Choice 1 | his | 
                  
                     
                     | Choice 2 | her | 
                  
                     
                     | Choice 3 | your | 
                  
                     
                     | Fill-in (15) |   | 
                  
                     
                     | Choice 1 | he | 
                  
                     
                     | Choice 2 | she | 
                  
                     
                     | Choice 3 | you | 
                  
                     
                     | Fill-in (16) |   | 
                  
                     
                     | Choice 1 | he chooses | 
                  
                     
                     | Choice 2 | she chooses | 
                  
                     
                     | Choice 3 | you choose | 
                  
                     
                     | Fill-in (17) |   | 
                  
                     
                     | Choice 1 | changes his | 
                  
                     
                     | Choice 2 | changes her | 
                  
                     
                     | Choice 3 | change your | 
                  
                     
                     | Fill-in (18) |   | 
                  
                     
                     | Choice 1 | his | 
                  
                     
                     | Choice 2 | her | 
                  
                     
                     | Choice 3 | your | 
               
            
          
         BEN010 – EXPLAINS TO THE WORKING BENEFICIARY THAT BENEFITS FOR A PRIOR YEAR ARE CHANGING
         We changed (1) benefits for (2). Our records show that (3) earned (4) in (5).
         
            
               
               
                  
                  
                     
                     | Fill-in values: |   | 
               
               
                  
                  
                     
                     | Fill-in (1) |   | 
                  
                     
                     | Choice 1 | your | 
                  
                     
                     | Choice 2 | Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) possessive | 
                  
                     
                     | Fill-in (2) | Year of Earnings Report (YOER) in format CCYY | 
                  
                     
                     | Fill-in (3)  |   | 
                  
                     
                     | Choice 1 | you | 
                  
                     
                     | Choice 2 | he | 
                  
                     
                     | Choice 3 | she | 
                  
                     
                     | Fill-in (4)  | Amount of Reported Earnings (AORE) in the format $$$$$¢¢ | 
                  
                     
                     | Fill-in (5) | Year of Earnings Report (YOER) in format CCYY | 
               
            
          
         BEN011 – EXPLAINS TO THE WORKING BENEFICIARY THAT HE OR SHE HAS BEEN INCORRECTLY PAID
               FOR THE CURRENT YEAR
         We changed (1) benefits for (2). Our records show that (3) to earn (4) (5).
         
            
               
               
                  
                  
                     
                     | Fill-in values: |   | 
               
               
                  
                  
                     
                     | Fill-in (1) |   | 
                  
                     
                     | Choice 1 | your | 
                  
                     
                     | Choice 2 | Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) | 
                  
                     
                     | Fill-in (2) | Year of Earnings Report (YOER) in format CCYY | 
                  
                     
                     | Fill-in (3)  |   | 
                  
                     
                     | Choice 1 | you expect | 
                  
                     
                     | Choice 2 | he expects | 
                  
                     
                     | Choice 3 | she expects | 
                  
                     
                     | Fill-in (4)  | Amount of Reported Earnings (AORE) in the format $$$$$¢¢ | 
                  
                     
                     | Fill-in (5) | this year | 
               
            
          
         BEN012 – EXPLAINS TO THE WORKING BENEFICIARY THAT HIS OR HER BENEFITS FOR MULTIPLE
               YEARS ARE CHANGING
         We changed (1) benefits for the following years:
         
            
               
               
                  
                  
                     
                     | Fill-in values: |   | 
               
               
                  
                  
                     
                     | Fill-in (1) |   | 
                  
                     
                     | Choice 1 | your | 
                  
                     
                     | Choice 2 | Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) | 
               
            
          
         BEN013 – A CHART HEADING UTI ALONG WITH BEN014, PROVIDES THE WORKING BENEFICIARY THE
               EARNINGS PREVIOUSLY ON THE RECORD AND THE EARNINGS NOW REPORTED
         Year Earnings You Reported Earnings On Our Records
         BEN014 – PROVIDES THE WORKING BENEFICIARY INFORMATION ABOUT EARNINGS PREVIOUSLY ON
               THE RECORD AND THE EARNINGS BEING NEWLY REPORTED IN A CHART - FOLLOWS BEN013
         (1) (2) (3)
         
            
               
               
                  
                  
                     
                     | Fill-in values: |   | 
               
               
                  
                  
                     
                     | Fill-in (1) | Year of Earnings Report (YOER) in format CCYY | 
                  
                     
                     | Fill-in (2) | Amount of Reported Earnings (AORE) in the format $$$$$¢¢ | 
                  
                     
                     | Fill-in (3) | Pre-MBR Amount of Reported Earnings (AORE) in the format $$$$$¢¢ | 
               
            
          
         BEN015 – TELLS THE BENEFICIARY THAT MONTHLY BENEFITS CAN BE PAID WHEN THE ANNUAL REPORT
               DATA IS CHANGING
         We can (1) pay (2) monthly benefits.
         
            
               
               
                  
                  
                     
                     | Fill-in values |   | 
               
               
                  
                  
                     
                     | Fill-in (1) |   | 
                  
                     
                     | Choice 1 | continue to | 
                  
                     
                     | Choice 2 | now | 
                  
                     
                     | Fill-in (2) |   | 
                  
                     
                     | Choice 1 | him | 
                  
                     
                     | Choice 2 | her | 
                  
                     
                     | Choice 3 | you | 
               
            
          
         BEN016 – LEDGER ACCOUNT FILE (LAF) S TO LAF S, NO CHANGE IN HISTORY REASON FOR SUSPENSION
               OR TERMINATION (HRFST) BUT MONTHLY BENEFIT AMOUNT (MBA) CHANGE
         We cannot pay (1) monthly benefits at this time.
         
            
               
               
                  
                  
                     
                     | Fill-in values: |   | 
               
               
                  
                  
                     
                     | Fill-in (1) |   | 
                  
                     
                     | Choice 1 | him | 
                  
                     
                     | Choice 2 | her | 
                  
                     
                     | Choice 3 | you | 
               
            
          
         BEN017 – EXPLAINS THE MONTH OR MONTHS BENEFITS WILL BE WITHHELD TO RECOVER AN OVERPAYMENT
         We must withhold your benefits for (1).
         
            
               
               
                  
                  
                     
                     | Fill-in values: |   | 
               
               
                  
                  
                     
                     | Fill-in (1) |   | 
                  
                     
                     | Choice 1 | Current Operating Month (COM) in the format Month CCYY | 
                  
                     
                     | Choice 2 | Current Operating Month (COM) plus ”and” plus the Deferred Payment Date -1 month in
                           the format Month CCYY
                         | 
                  
                     
                     | Choice 3 | Current Operating Month (COM) plus ”through” plus the Deferred Payment Date -1 month
                           in the format Month CCYY
                         | 
               
            
          
         BEN019 – THIS PARAGRAPH SHOULD BE ON ALL NOTICES WHERE SUPPLEMENTAL SECURITY INCOME
               (SSI) WINDFALL OFFSET IS INVOLVED
         The Social Security benefits you receive count as income and resources and can lower
            the amount of SSI payments you can receive. When a person receives SSI money for a
            month and later becomes entitled to Social Security for the same month, we have to
            refigure the SSI payment. We hold back some of the Social Security benefits while
            we do this, so the person doesn't owe us if we've paid too much SSI.
         
         BEN021 – SUPPLEMENTAL SECURITY INCOME (SSI) WINDFALL OFFSET IS DETERMINED AND THE
               HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF WINDFALL OFFSET (WINFAL) IS
               REMOVED
         In an earlier letter, we told you that (1) entitled to Social Security but that we
            were holding back benefits for (2). We withheld (3) in Social Security benefits.
         
         We did this because our records showed (4) could have been getting Supplemental Security
            Income (SSI) when we started paying (5) Social Security benefits. And Social Security
            benefits can lower the amount of SSI payments (6) can receive.
         
         
            
               
               
                  
                  
                     
                     | Fill-in values: |   | 
               
               
                  
                  
                     
                     | Fill-in (1) |   | 
                  
                     
                     | Choice 1 | Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) plus ”was” | 
                  
                     
                     | Choice 2 | you were | 
                  
                     
                     | Choice 3 | you | 
                  
                     
                     | Fill-in (2) |   | 
                  
                     
                     | Choice 1 | History Start date of the first month where Reason for Suspension = WINFAL in the
                           format Month CCYY
                         | 
                  
                     
                     | Choice 2 | Start date that corresponds to the Reason for Suspension = WINFAL plus ”and” plus
                           the Stop date of the last WINFAL Suspension month in the format Month CCYY
                         | 
                  
                     
                     | Choice 3 | History Start date of the first month where Reason for Suspension = WINFAL plus “through”
                           plus the Stop date of the last WINFAL Suspension month in the format Month CCYY
                         | 
                  
                     
                     | Fill-in (3) | Windfall Total Amount (WTA) in the format $$$$$.¢¢ | 
                  
                     
                     | Fill-in (4) |   | 
                  
                     
                     | Choice 1 | Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) | 
                  
                     
                     | Choice 2 | you | 
                  
                     
                     | Fill-in (5) |   | 
                  
                     
                     | Choice 1 | him | 
                  
                     
                     | Choice 2 | her | 
                  
                     
                     | Choice 3 | you | 
                  
                     
                     | Fill-in (6) |   | 
                  
                     
                     | Choice 1 | he | 
                  
                     
                     | Choice 2 | she | 
                  
                     
                     | Choice 3 | you | 
               
            
          
         BEN022 – EXPLAINS TO THE BENEFICIARY STARTING FULL RETIREMENT AGE (FRA) THAT BENEFITS
               ARE NO LONGER WITHHELD
         Since (1) (2) full retirement age in (3), we will not withhold (4) benefits because
            of earnings in that month or later.
         
         
            
               
               
                  
                  
                     
                     | Fill-in values: |   | 
               
               
                  
                  
                     
                     | Fill-in (1) |   | 
                  
                     
                     | Choice 1 | Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) | 
                  
                     
                     | Choice 2 | you | 
                  
                     
                     | Fill-in (2) |   | 
                  
                     
                     | Choice 1 | was | 
                  
                     
                     | Choice 2 | will be | 
                  
                     
                     | Choice 3 | were | 
                  
                     
                     | Fill-in (3) | Full Retirement Age (FRA) attainment in the format Month CCYY | 
                  
                     
                     | Fill-in (4) |   | 
                  
                     
                     | Choice 1 | his | 
                  
                     
                     | Choice 2 | her | 
                  
                     
                     | Choice 3 | your | 
               
            
          
         BEN023 – INFORMS THE BENEFICIARY OF THE OPTION TO EARN VOLUNTARY DELAYED RETIREMENT
               CREDITS (DRC)
         In this letter, we explain that (1) can choose to delay being paid benefits now. If
            (2) retirement benefits, (3) can earn special credit that may increase the amount
            of benefits (4) later.
         
         
            
               
               
                  
                  
                     
                     | Fill-in values: |   | 
               
               
                  
                  
                     
                     | Fill-in (1) |   | 
                  
                     
                     | Choice 1 | you | 
                  
                     
                     | Choice 2 | Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) | 
                  
                     
                     | Fill-in (2) |   | 
                  
                     
                     | Choice 1 | you delay | 
                  
                     
                     | Choice 2 | he delays | 
                  
                     
                     | Choice 3 | she delays | 
                  
                     
                     | Fill-in (3) |   | 
                  
                     
                     | Choice 1 | you | 
                  
                     
                     | Choice 2 | he | 
                  
                     
                     | Choice 3 | she | 
                  
                     
                     | Fill-in (4) |   | 
                  
                     
                     | Choice 1 | you receive | 
                  
                     
                     | Choice 2 | he receives | 
                  
                     
                     | Choice 3 | she receives | 
                  
                     
                     | Choice 4 | Beneficiary’s Given Name (BGN) plus “receives” | 
               
            
          
         BEN026 – TELLS THE BENEFICIARY THERE IS NO ADJUSTMENT OF BENEFITS AT THIS TIME
         No change to (1) benefits is necessary at this time.
         
            
               
               
                  
                  
                     
                     | Fill-in values: |   | 
               
               
                  
                  
                     
                     | Fill-in (1) |   | 
                  
                     
                     | Choice 1 | your | 
                  
                     
                     | Choice 2 | his | 
                  
                     
                     | Choice 3 | her | 
                  
                     
                     | Choice 4 | Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) | 
               
            
          
         BEN028 – EARNINGS CHANGE TO ZERO IN A PRIOR YEAR OR YEARS AND BENEFITS ARE CHANGING
         We changed (1) benefits for (2). Our records show that (3) did not have any earnings
            in (4).
         
         
            
               
               
                  
                  
                     
                     | Fill-in values: |   | 
               
               
                  
                  
                     
                     | Fill-in (1) |   | 
                  
                     
                     | Choice 1 | your | 
                  
                     
                     | Choice 2 | Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) | 
                  
                     
                     | Fill-in (2) |   | 
                  
                     
                     | Choice 1 | Year benefits changed in the format CCYY | 
                  
                     
                     | Choice 2 | and | 
                  
                     
                     | Choice 3 | comma (,) | 
                  
                     
                     | Fill-in (3)  |   | 
                  
                     
                     | Choice 1 | you | 
                  
                     
                     | Choice 2 | he | 
                  
                     
                     | Choice 3 | she | 
                  
                     
                     | Fill-in (4)  |   | 
                  
                     
                     | Choice 1 | Year of no earnings in the format CCYY | 
                  
                     
                     | Choice 2 | and | 
                  
                     
                     | Choice 3 | comma (,) | 
               
            
          
         BEN029 – EARNINGS CHANGE TO ZERO ONLY IN THE CURRENT YEAR AND BENEFITS ARE CHANGING
               - THIS UTI WILL ONLY APPEAR ON A WORKING BENEFICIARY NOTICE
         We changed (1) benefits for (2). Our records show that (3) not plan to have any earnings
            (4).
         
         
            
               
               
                  
                  
                     
                     | Fill-in values: |   | 
               
               
                  
                  
                     
                     | Fill-in (1) |   | 
                  
                     
                     | Choice 1 | your | 
                  
                     
                     | Choice 2 | Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) | 
                  
                     
                     | Fill-in (2) | Year benefits changed in the format CCYY | 
                  
                     
                     | Fill-in (3)  |   | 
                  
                     
                     | Choice 1 | you do | 
                  
                     
                     | Choice 2 | he does | 
                  
                     
                     | Choice 3 | she does | 
                  
                     
                     | Fill-in (4)  | this year | 
               
            
          
         BEN045 – NON-SERVICE MONTHS CHANGE FOR A PAST PERIOD
         (1) due full benefits for (2). This is because we used a special rule to count (3)
            earnings. We explain this rule in the enclosed fact sheet, "How Work Affects Your
            Social Security."
         
         
            
               
               
                  
                  
                     
                     | Fill-in values: |   | 
               
               
                  
                  
                     
                     | Fill-in (1) |   | 
                  
                     
                     | Choice 1 | Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) plus “was” | 
                  
                     
                     | Choice 2 | You were | 
                  
                     
                     | Fill-in (2) |   | 
                  
                     
                     | Choice 1 | First non-service month greater than or equal to the Current Date of Entitlement (DOEC)
                           in the format Month CCYY
                         | 
                  
                     
                     | Choice 2 | and | 
                  
                     
                     | Choice 3 | through | 
                  
                     
                     | Choice 4 | comma (,) | 
                  
                     
                     | Fill-in (3) |   | 
                  
                     
                     | Choice 1 | his | 
                  
                     
                     | Choice 2 | her | 
                  
                     
                     | Choice 3 | your | 
               
            
          
         BEN050 – INFORMATIONAL - BENEFICIARY TERMINATES DUE TO MARRIAGE
         We might still be able to pay (1) if (2) married a person who is receiving Social
            Security benefits. Please get in touch with us if this is true.
         
         
            
               
               
                  
                  
                     
                     | Fill-in values: |   | 
               
               
                  
                  
                     
                     | Fill-in (1) |   | 
                  
                     
                     | Choice 1 | Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) | 
                  
                     
                     | Choice 2 | you | 
                  
                     
                     | Fill-in (2) |   | 
                  
                     
                     | Choice 1 | he | 
                  
                     
                     | Choice 2 | she | 
                  
                     
                     | Choice 3 | you | 
               
            
          
         BEN051 – DUALLY ENTITLED - COMBINE PAYMENTS
         We will send (1) both benefits in one check each month under (2) own Social Security
            claim number.
         
         
            
               
               
                  
                  
                     
                     | Fill-in values: |   | 
               
               
                  
                  
                     
                     | Fill-in (1) |   | 
                  
                     
                     | Choice 1 | Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) | 
                  
                     
                     | Choice 2 | you | 
                  
                     
                     | Fill-in (2) |   | 
                  
                     
                     | Choice 1 | your | 
                  
                     
                     | Choice 2 | his | 
                  
                     
                     | Choice 3 | her | 
               
            
          
         BEN052 – DUALLY ENTITLED - SPLIT PAYMENTS
         We will send (1) separate checks each month under each Social Security claim number.
         
            
               
               
                  
                  
                     
                     | Fill-in values: |   | 
               
               
                  
                  
                     
                     | Fill-in (1) |   | 
                  
                     
                     | Choice 1 | Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) | 
                  
                     
                     | Choice 2 | you | 
               
            
          
         BEN057 – LEDGER ACCOUNT FILE (LAF) S TO LAF S MONTHLY BENEFIT AMOUNT (MBA) CHANGE
               - NO HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) CHANGE
         We cannot pay (1) monthly benefits for (2).
         
            
               
               
                  
                  
                     
                     | Fill-in values: |   | 
               
               
                  
                  
                     
                     | Fill-in (1) |   | 
                  
                     
                     | Choice 1 | him | 
                  
                     
                     | Choice 2 | her | 
                  
                     
                     | Choice 3 | you | 
                  
                     
                     | Fill-in (2) |   | 
                  
                     
                     | Choice 1 | this month | 
                  
                     
                     | Choice 2 | these months | 
               
            
          
         BEN103 – MONTHLY BENEFIT REDUCED DUE TO RECEIPT OF A GOVERNMENT PENSION – BENEFICIARY
               IDENTIFICATION CODE (BIC) B, D, E OR W ONLY
         We reduce Social Security benefits paid to (1) if they also receive a government pension
            based on their own work. We reduce benefits by two-thirds of the amount of the pension.
            For this reason, we are reducing (2) benefits beginning (3), by (4).
         
         
            
               
               
                  
                  
                     
                     | Fill-in values: |   | 
               
               
                  
                  
                     
                     | Fill-in (1) |   | 
                  
                     
                     | Choice 1 | husbands | 
                  
                     
                     | Choice 2 | wives | 
                  
                     
                     | Choice 3 | widows | 
                  
                     
                     | Choice 4 | widowers | 
                  
                     
                     | Fill-in (2) |   | 
                  
                     
                     | Choice 1 | your | 
                  
                     
                     | Choice 2 | Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) | 
                  
                     
                     | Fill-in (3) | Government Pension Monthly Start Date (GPM-START-REL) in the format Month CCYY | 
                  
                     
                     | Fill-in (4) | Government Pension Monthly Amount Withheld (GPM-WTHLD-AMT) in the format $$$$$.¢¢ | 
               
            
          
         BEN125- REFER TO “YOUR MONTHLY BENEFITS” FACT SHEET
         Please see the enclosed Fact Sheet “Your Monthly Benefits” for more information on
            (1) (2).
         
         
            
               
               
                  
                  
                     
                     | Fill-in values: |   | 
               
               
                  
                  
                     
                     | Fill-in (1) |   | 
                  
                     
                     | Choice 1 | your | 
                  
                     
                     | Choice 2 | his | 
                  
                     
                     | Choice 3 | her | 
                  
                     
                     | Fill-in (2) |   | 
                  
                     
                     | Choice 1 | overpayment | 
                  
                     
                     | Choice 2 | underpayment |