FORMAL PROTEST
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TO:
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DATE:
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FROM:
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Department of the Treasury
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Social Security Administration
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Bureau of Fiscal Service
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(Insert local address)
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Philadelphia Financial Center
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13000 Townsend Rd
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Philadelphia, PA 19154
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The following claimant is filing a formal protest on the handwriting analysis made
by your office.
BENEFICIARY / RECEIPIENT’S NAME ______________________________
BENEFICIARY / RECEIPIENT’S ADDRESS ___________________________________________________________
SSN _____________________________
PROGRAM (check one): ____ SSI (Title XVI) or _____ SSA (Title II) _____
CHECK NUMBER __________ CHECK SYMBOL ____________
CHECK DATE__________ CHECK AMOUNT ____________
ADDITIONAL INFORMATION __________________________
BENEFICIARY / RECEIPIENT’S SIGNATURE _________________
Please contact the person named below if you have any questions.
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(Insert Employee’s Name)
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(Insert Position)
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(Insert Office Address)
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(Insert Telephone)
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Attachments ( )
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