TN 30 (03-96)
NL 00703.120 Notice to Beneficiary(ies') When a Claim Has Been Filed That Will Require an Adverse Adjustment to the Beneficiary's(ies') Benefits
Document Identifier for Word Processor: E3120
A. Exhibit Letter
We are writing to tell you that we plan to reduce (1) Social Security benefits (2) to $ (3) as of (4) because (5) filed for benefits as the (6) of (7) . Here is what we were given as proof:
We plan to pay benefits to (9) . When we do this, we will reduce the benefits you receive. This is because we have a limit on how much we can pay on each person's Social Security record.
If You Disagree With The Decision
Please tell us within 101 days of the date of this letter if you disagree with the decision. You will also need to give us any proof that your benefits should not be reduced.
If you let us know within 101 days that you disagree with the decision, we will not reduce your checks. We will continue to pay you while we review the case to see if you are right. However, if you are wrong we will ask you to pay back any money you received that was not due.
If we do not hear from you within 101 days, we will reduce your checks. We will send you another letter at that time with more information about our action.
If You Have Any Questions
3901C - Domestic
3901D - Foreign
B. Requesting Instructions
your, or Name of Beneficiary (possessive case)
if the beneficiary is receiving benefits directly and is also representative payee for others whose benefits may be affected, then: “and the check you receive for (name(s) of other beneficiaries.)” (Otherwise null)
month/year change is effective
name of new claimant (if an adopted child living in another household, do not show new adoptive name. Instead, show the child's first name and age)
relationship of new claimant to Number Holder, e.g. wife, child, etc.
name of Number Holder
explanation of evidence (paragraph should be indented 3 spaces from left margin)
name of new claimant (see fill-in 5)
Refer to NL 00703.005E for 3901C and 3901D text and fill-ins.
C. Typing Instructions
Use Form SSA-L2000-C2 (Universal Notice) and follow the notice standards. Information for this notice will be shown on Form SSA-573.
1 For foreign beneficiaries, 30 days.