Send when accrued benefits were withheld at the time benefits were awarded and the
entire withheld amount is to be paid to the representative payee or directly to the
Leave blank in direct pay cases. Otherwise, show “for (full name of beneficiary)”, in the format, for June Sampson
In direct pay cases show “You are”. Otherwise, show “(first name of beneficiary) is” in the format, June is, if child; if adult, show “Mr.” or “Ms.” is, in format, Ms. Sampson.
Total amount of money due
First month, year accrued benefits were withheld, in the format of June 1992
Last month, year accrued benefits were withheld
Month, day, year payment is due, in the format of July 3, 1993
Optional Paragraph 3350A:
beneficiary's first name, if a child; if an adult, “Mr.” or “Ms.” last name
Use paragraph 3350A only when we pay the accumulated benefits to a payee and the type
of payee code (TYP) is not SLM. Otherwise, omit the paragraph.
See NL 00703.005E. for 3901C and D text and fill-in.