We are writing to tell you that we learned (1) a pension based on work not covered by Social Security. When (2) this type of pension, we must use a special formula to figure (3) monthly benefits from us. (4) benefit amount will be less than (5) would receive if (6) not getting the pension.
The Information We Have
We matched our computer records with the Office of Personnel Management’s records.
We learned the following about (7) pension.
Please read the enclosed fact sheet, “Windfall Elimination Provision.” This fact sheet will give you more information about how a pension affects benefits.
What You Can Do
Please let us know right away if any of this information is wrong. We cannot use this
information to figure Social Security benefits until we give you time to check it.
You will also need to give us any proof you have that shows that our information is
If We Do Not Hear From You
If we do not hear from you within 30 days of the date on this letter, we will assume
the information we have is correct. We will use this special formula to figure (10) benefits from us.
We will send another letter at that time. It will explain how to appeal our decision.
You will have 60 days to ask for an appeal.
The 60 days will start the day after you receive the next letter.
If You Have Any Questions
3901C - Domestic
3901D - Foreign
SSA Pub. No. 05-10045