You asked us to hold back $ (1) from your checks each month because of your work. We will hold back this amount from
your checks for (2) through (3) .
What We Will Pay And When
You will receive $ (4) around (5) . This includes a (6) of $ (7) for medicare premiums you (8) .
After that, you will receive $ (9) each month. This is the amount you asked to receive each month, less your monthly
medicare premium of $ (10) .
If you expect to earn more or less than $ (11) this year, please let us know right away. Any change in the amount of money you earn
may change your payments.
At the end of the year, we will send you a form called the “Annual Report of Earnings.” You will need it to report how much you actually earn for the year. After you report,
we will make any necessary changes to your benefits because of the earnings.
If You Have Any Questions
3901C - Domestic