We are writing to let you know that (1) saved $ (2) for you. They will send this money to you within the next 30 days.

 

What You Can Do

If you do not already have this money, or you do not receive it in the next 30 days, you should contact them. We are sending a copy of this letter to them. That way they will know that you may try to reach them. If you have any problems, please let us know.

 

If You Have Any Questions

3901C - Domestic

3901D - Foreign

cc: (8)

Send this letter when direct transfer of conserved funds has been authorized. Listed below are the fill-ins:

1. (1) 

   name of former payee, in the format of Mark Jones or Johnson Nursing Home

2. (2) 

   amount of conserved funds in the format of 365.00

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

Use Form SSA-L2000-C2 (Universal Notice) and follow the notice standards. Information for this notice will be shown on Form SSA-573. For SSI cases use FO letterhead. Copy of notice must be sent to former payee. (Fill-in #4.)