Prescription Drug Assistance
November 23, 2005
Security Number: 123-00-6789
JOHN Q. PUBLIC
123 MAIN ST
SPRINGFIELD OH 45501
Based on an appeal filed by your spouse, we may change the amount of your subsidy.
We are writing to tell you that you can present additional information for us to consider
before we make a decision on your spouse’s appeal.
Providing Additional Information
If there is more information you want us to see, please send it to us within 10 days
from the date of this notice. You can mail the information to Social Security Administration,
to be determined) or you can call us at (special
800#). If you need help, you should contact us immediately.
If you do call, please have this letter with you. It will help us answer your questions.
Determination Unit Supervisor