Social Security Administration
               Retirement, Survivors, and Disability Insurance
               Important Information
                
                                                                                           Date:
                                                                                           Claim
                  Number: XXX-XX-XXXXA
               
                
               JOHN G. BENEFICIARY
               101 MAIN STREET
               ANYTOWN, ST 00001
                
               What We Will Pay And When
               Your monthly benefit is $500.00 beginning 03/2005.
               Our Decision
               Based on the information you have provided us, we can grant good cause for not satisfying
                  the outstanding warrant beginning 01/2005 because you are residing in a long-term
                  care facility.
               
               Other Social Security Benefits
               The benefits described in this letter are the only ones to which you are entitled
                  from Social Security. If you think you might qualify for another kind of Social Security
                  benefit in the future, you will have to file another application.
               
               If You Disagree With The Decision
               If you disagree with this decision, you have the right to appeal. We will review your
                  case and consider any new facts you have. A person who did not make the first decision
                  will decide your case. We will correct any mistakes. We will review those parts of
                  the decision which you believe are wrong and will look at any new facts you have.
                  We may also review those parts which you believe are correct 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 get 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 must have a good reason for waiting 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 SSA-561-U2,
                  called "Request for Reconsideration." Contact one of our offices if you want help.
               
               Please read the enclosed pamphlet, "Your Right to Question the Decision Made on Your
                  Social Security Claim." It contains more information about the appeal.
               
               If You Want Help With Your Appeal
               You can have a friend, representative, or someone else help you. There are groups
                  that can help you find a representative or give you free legal services if you qualify.
                  There are also representatives who do not charge unless you win your appeal. Your
                  Social Security office has a list of groups that can help you with your appeal. If
                  you get someone to help you, you should let us know. If you hire someone, we must
                  approve the fee before they can collect it.
               
               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, “Your Social Security Rights and Responsibilities.” It
                  tells you what you must be reported and how to report. Please be sure to read the
                  part of the pamphlet which explains how work could changes your payments.
               
               If You Have Any Questions
               We invite you to visit our website at www.socialsecurity.gov on the Internet to find
                  general information about Social Security. If you have any specific questions, you
                  may call us toll-free at 1-800-772-1213, or call your local Social Security office
                  at 1-610-433-3237. We can answer most questions over the phone. If you are deaf or
                  hard of hearing, you may call our TTY number, 1-800-325-0778. You can also write or
                  visit any Social Security office. The office that serves your area is located at:
               
               SOCIAL SECURITY 
 41 N 4TH ST 
 ALLENTOWN, PA 18102
               
               If you do call or visit an office, please have this letter with you. It will help
                  us answer your questions. Also, if you plan to visit an office, you may call ahead
                  to make an appointment. This will help us serve you more quickly when you arrive at
                  the office.  
               
               
                  
                     NOTE: The general referral paragraph and the appropriate signature are also required for
                        the notice. See NL 00601.040 for additional paragraphs required on post-entitlement notices; e.g., overpayment
                        or underpayment paragraphs, etc. See NL 00601.003 for name and signature requirements on notices.