TN 66 (04-15)

NL 00703.312 Miscellaneous Adjustment Notice (Representative Payee)

Document Identifier for Aurora: E3312

A. Who is this notice for?

This notice is sent to the representative payee. Refer to NL 00703.311B. (E3311 notice) instructions on when to use this notice.

B. Exhibit notice

We are writing to tell you about a change in the Social Security checks you receive for (1) . The rest of this letter will tell you why we are changing the checks, what we will pay, and when the checks will (2) .

Why We Are Changing the Checks

(3)

What We Will Pay and When

  • You will receive $ (4) around (5) . This is the money (6) is due for (7). (8).

  • After that, you will receive $ (9) each month. (10).

If You Disagree With the Decision (ALSC04)

If you do not agree with this decision, you have the right to appeal. We will review your case and look at any new facts you have. A person who did not make the first decision will decide your case. We will review the parts of the decision that you think are wrong and correct any mistakes. We may also review the parts of our decision that you think are right. We will make a decision that may or may not be in your favor.

  • You have 60 days to ask for an appeal in writing.

  • The 60 days start the day after you receive 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 if you wait more than 60 days to ask for an appeal.

You can file an appeal with any Social Security office. You must ask for an appeal in writing. Please use our "Request for Reconsideration" form, SSA-561. You may go to our website at *F1 to find the form SSA-561. You can also contact us by phone, mail, or come into an office to request the form. If you need help to fill out the form, we can help you by phone or in person. (ALS020)

If You Want Help With Your Appeal1 (REPC01)

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 also are representatives who do not charge unless you win your appeal. Your local 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 he or she can collect it. And if you hire a representative who is eligible for direct pay, we will withhold up to 25 percent of any past due benefits to pay toward the fee. (REP001)

Your Responsibilities

If the information you have given us changes, it could affect the benefits. For this reason, it is important that you report changes to us right away.

You should report any changes that are described in the pamphlet, “A Guide for Representative Payees.” We sent you one of these pamphlets when you first became a payee. If you need another pamphlet, you can get one from any Social Security office.2 Please be sure to read the part of the pamphlet which explains how payments could change if (11) has earnings from work.

If You Have Any Questions

CTDO - Domestic

3901D - Foreign

1 If the person lives outside the U.S. or has an attorney, omit this paragraph.

2 If the person lives outside the U.S., substitute “the office shown below,” for “any Social Security office.”

C. Fill-ins

  1. full name of beneficiary

  2. change, or start

  3. Add standard or dictated paragraph to explain why payment is being resumed/changed

  4. amount of next payment

  5. month/day/year when payment should be received (in format of February 8, 1992)

  6. beneficiary name

  7. months for which payment is due. First month is first month payment is due. Last month is last month used to figure PMA. Format is “January through October” unless period spans 2 calendar years. If so, format is “January 1992 through October 1993.”

  8. If Medicare deduction applies, then:
    “We took out $(8A) for Medicare premiums for (8B).”

  9. (8A)amount of premium deducted for Medicare

  10. (8B)month or months for which premium is deducted

  11. ongoing MPA in format $$$¢¢

  12. If Medicare deduction applies, then:
    “This amount is your regular monthly benefit, minus $(10A) for your monthly Medicare premium.”

  13. (10A)amount to be deducted for premium

  14. beneficiary's first name, if child; otherwise Mr. or Ms. last name of b