We are writing to let you know that (1) entitlement to benefits ended as of (2) . We based this on information that (3) (4) in (5) .

 

Other Social Security benefits

3923A

OR

3923B

 

If you disagree with the decision¹

ALS020

 

If you have any questions

3901D

¹ If there is an overpayment, omit this paragraph.

• •

  Send when spouse, child, mother/father marries or divorces and benefits are terminated. Also, send when mother/father benefits end because last child-in-care marries.

• •

  Use paragraph 3923A when benefits to mother/father terminate because last child-in-care marries. Use paragraph 3923B when benefits to young spouse terminate because last child-in-care marries. See NL 00703.923 for text and fill-in. See
  
  NL 00703.005E. for 3901D text and fill-in. See NL 00703.180 for ALS020 text.

   

Fill-ins:

1. (1) 

   your, full name of beneficiary, possessive format

2. (2) 

   last month/year of entitlement e.g., May 1993

3. (3) 

   you/he/she, name of beneficiary when parent's entitlement ends due to marriage of child-in-care

4. (4) 

   was married/were married/were divorced/was divorced

5. (5) 

   month/year e.g., June 1993

3925A

1. (1) 

   mother's/father's/young spouse's

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