When (1) got (2) checks for (3)   (4) should have used this money for (5) needs. Some time ago we told you that (6) had used $(7) incorrectly. We have been trying to collect this money so that we can pay it to you, but (8) not paid us back.

We are writing to let you know that there is nothing more we can do to collect this money. We also want to tell you what you can do to try to get the money back.

 

Our Decision Is Based On These Facts

(9)

 

What You Can Do

There is nothing more we can do to collect this money. If you want to contact (10) about it yourself, the most recent address we have for (11) is (12) .

If You Have Any Questions

3901C - Domestic

3901D - Foreign

In title II cases, the recovery reviewer sends this notice to the new payee when the decision is made to abandon efforts to recover misused funds. In title XVI cases, this is sent by the FO.

 

Fill-ins:

1. (1) 

   name of former payee

2. (2) 

   Social Security, Supplemental Security Income, Black Lung, Social Security and Supplemental Security Income

3. (3) 

   full name of beneficiary, you

4. (4) 

   he, she, they

5. (5) 

   your, first name of beneficiary-possessive, if child; if adult, “Mr.” or “Ms.” last name—possessive

6. (6) 

   name of former payee

7. (7) 

   amount of misused funds

8. (8) 

   he has, she has, they have

9. (9) 

   reason for abandonment decision

10. (10) 

    name of former payee

11. (11) 

    him, her, them

12. (12) 

    address of former payee

See NL 00703.005E. for 3901C and D text and fill-in.

Use Form SSA-L2000-C2 (Universal Notice) and follow the new notice standards for title II and Black Lung. Information for this notice will be shown on Form SSA-573. For title XVI cases use FO letterhead.