We are writing to tell you about a check we are sending you (1) .

What We Will Pay and When

• •

  You will get $(2) around (3) .

• •

  This is the money that (4) last representative payee saved for (5) and returned to us.

If You Have Any Questions

3901C - Domestic

3901D - Foreign

Send when the entire amount of conserved benefits returned by the former representative payee is being paid to the new payee or to the beneficiary.

Fill-ins:

1. (1) 

   Leave blank in direct pay cases. Otherwise, show:
   
   “for name of beneficiary” in the format, for John Davies

2. (2) 

   Amount of conserved fund payment

3. (3) 

   month, day, year payment is due in the format of July 3, 1992

4. (4) 

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

5. (5) 

   you, them

    

Optional Paragraph 3350A:

1. (1) 

   Beneficiary's first name, if child; “Mr.” or “Ms.” last name if adult.

Use paragraph 3350A only when we pay the conserved benefits to a representative payee and the type of payee code (TYP) is not SLM.

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.