We are writing to tell you about a change in the children's checks. We will reduce these checks beginning (1) because we were told that (2) plans to earn $ (3) this year.

What We Will Pay And When

• •

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

• •

  After that, you will receive $ (7) each month.

• •

  Your check is the combined amount due the children. The benefit amount for each child is:

  •  

    Name
    
    Payment Amount

    (8)
    
    $ (9)

     

Your Responsibilities

Please let us know right away if there are changes in the amount of money (10) expects to earn. This will help us make sure that we are paying the correct check amounts.

If You Have Any Questions

3901C

Use this notice when a combined payment is reduced because one of the children submits an estimate of earnings that cause a partial or total deduction of his /her benefits, resulting in a decrease in the total amount of the combined payment.

Fill-ins:

1. (1) 

   effective month/year of change, e.g., June 1992

2. (2) 

   full name of working child

3. (3) 

   amount of working child's earnings

4. (4) 

   amount of next check

5. (5) 

   date of next check, e.g., July 3, 1992

6. (6) 

   effective month/year of change

7. (7) 

   continuing MPA

8. (8) 

   list names if each child

9. (9) 

   list payment amounts of each child

10. (10) 

    first name of working child

Refer to NL 00703.005E. for 3901C text.

Use SSA-L2000-C2 (Universal Notice) and follow the notice standards. Information for this letter will be shown on Form SSA-573.