We are writing to let you know that we are stopping (1) Social Security benefits in

(2) . This is the check you would normally receive on (3) .

(4) benefits are stopping because you have not returned the form, (5) . We need the information requested on this form to decide if (6) can receive benefits again.

 

What You Need To Do

We have enclosed another copy of the form with this letter. Please complete this form and return it to us in the enclosed envelope.

Once we get this information, we will let you know if (7) can still receive benefits.

 

If You Have Any Questions

3901D

 

Enclosures:

Envelope

(8)

This notice is used when a beneficiary has not returned the Form SSA-7161-OCR-SM, SSA-7162-OCR-SM and/or SSA-21 as requested. Refer to NL 00703.005E. for 3901D text and fill-ins.

 

Fill-ins:

1. (1) 

   your, full name of beneficiary - possessive

2. (2) 

   month/year; e.g., July 1992

3. (3) 

   month/day/year; e.g., August 03, 1992

4. (4) 

   your, his, her, their

5. (5) 

   name of form(s) (SSA-7161–OCR-SM, Report to United States Social Security Administration), (SSA-7162–OCR-SM, Report to United States Social Security Administration) and/or (SSA-21, Supplement to Claim of Person Outside the United States)

6. (6) 

   you, he, she, they

7. (7) 

   you, he, she, they

8. (8) 

   SSA-7161-OCR-SM, SSA-7162-OCR-SM and/or SSA-21

Use Form SSA-L-2000-C2 (Universal Notice) and follow the new notice standards.

Information for this letter will be shown on Form SSA-573. Based on the originating office's instructions, the enclosures needed will be provided by the typist and/or mailroom.