We are writing to tell you that (1) for (2) benefits for $ (3) beginning (4) . However, we cannot pay you benefits for (5) at this time.
Why We Cannot Pay You
We cannot pay you benefits for (6) because you did not (7) . We can only pay (8) if
(9) a number . If you decide later to (10) , please contact any Social Security office.
Other Social Security Benefits
The benefits described in this letter are the only ones you can receive from Social
Security. If you think that you might qualify for another kind of Social Security
benefit in the future, you will have to file another application.
Your benefits are based on the information you gave us. If this information changes,
it could affect your benefits. For this reason, it is important that you report changes
to us right away.
We have enclosed a pamphlet, “When You Get Social Security Retirement and Survivors Benefits... What You Need to
Know.” It tells you what must be reported and how to report. Please be sure to read that
part of the pamphlet which explains how work could change your payments.
If You Disagree With The Decision
If You Want Help With Your Appeal 1
If You Have Any Questions
3901C - Domestic
3901D - Foreign
1 If the beneficiary lives outside the U.S. or has an attorney, omit this paragraph.