We are writing to tell you that you qualify for (1) benefits of $ (2) beginning (3) . However, we cannot pay you at this time.

 

Why We Cannot Pay You

We cannot pay you benefits because you did not (4) . We can only pay you if you have a number. If you decide later to (5) , please contact any Social Security office.

 

Other Social Security Benefits

The benefits described in this letter are the only ones you can receive from Social Security. If you think that you might qualify for another kind of Social Security benefit in the future, you will have to file another application.

 

Your Responsibilities

Your benefits are based on the information you gave us. If this information changes, it could affect your benefits. For this reason, it is important that you report changes to us right away.

We have enclosed a pamphlet, “When You Get Social Security Retirement or Survivors Benefits...What You Need To Know.” It tells you what must be reported and how to report. Please be sure to read that part of the pamphlet which explains how work could change your payments.

 

If You Disagree With The Decision

3462A

If you disagree with the decision, you have the right to appeal. A person who did not make the first decision will decide your case. We will review those parts of the decision you disagree with and consider any new facts you have. We may also review those parts which you agree with and may make them unfavorable or less favorable to you.

• •

  You have 60 days to ask for an appeal

• •

  The 60 days start the day after you receive this letter. We assume you got this letter 5 days after the date on it, unless you show us that you did not get it within the 5-day period.

• •

  You will have to have a good reason if you wait more than 60 days to ask for an appeal.

• •

  You have to ask for an appeal in writing. We will ask you to sign a form called “Request for Reconsideration.” The form number is SSA-561-U2. To get this form, contact one of our offices. We can help you fill out the form.

 

If You Want Help With Your Appeal¹

3100E

 

If You Have Any Questions

3901C - Domestic

3901D - Foreign

  

¹ If the beneficiary has an attorney or lives outside the U.S., omit this paragraph.

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  Use this notice when an auxiliary claimant does not have a Social Security number.

• •

  Include any other necessary paragraphs.

• •

  Refer to NL 00703.005 for 3901C and 3901D text and fill-in. Refer to NL 00703.100 for 3100E text.

   

Fill-ins:

1. (1) 

   Type of benefit, in the format, “spouse's,” “widow's,” “parent's, ” “mother's,” etc.

2. (2) 

   Monthly payment amount

3. (3) 

   Current date of entitlement, in the format, “July 1992.”

Use SSA-L2000-C2 (Universal Notice) and follow the notice standards. Information for this notice will be shown on SSA-573.