TN 31 (02-97)
NL 00703.512 Due Process Notice To Disabled NH — Auxiliary Benefits To Be Reduced, Further Reduced, or Withheld Because of NH's Initial Receipt of Or Increase in WC, PDB, FECA or BL Payments (Computer Match Only)
Document Identifier for Word Processor: E3512
A. EXHIBIT LETTER
We are writing to tell you that we plan to (1) (2) family's Social Security benefits because we learned that (3) (4) (5) payments. Based on the information we have, we should have (6) the Social Security benefits beginning (7) .
The Information We Have
When we matched computer records with the (8) , we learned the following information about (9) (10) payments:
|Monthly Payment (s)||Effective Date(s)|
|$ (11) || (12) |
| (13) || |
What You Can Do
Please let us know right away if any of this information is wrong. We cannot use this information to change Social Security benefits until we give you time to check it. You will also need to give us any proof you have that shows that our information is wrong.
If We Do Not Hear From You
If we do not hear from you within 30 days from the date of this letter, we will assume the information in this letter is correct and use it to (14) (15) family's benefits.
We will send (16) family a letter at that time. It will explain the change in (17) family's benefits, the amount of any overpayment, and how to appeal our decision.
If You Have Any Questions
B. REQUESTING INSTRUCTIONS
your/full name of disabled worker, possessive
receive/receives/received an increase in
workers' compensation/public disability/black lung/federal employees compensation
month and year that offset should have begun or changed
name of organization paying the benefit
your/disabled worker's title and surname, possessive
(Same as 5.)
amount(s) of WC, PDB, FECA or BL payments
effective month(s) and year(s) of WC, PDB, FECA or BL payments
If the disabled worker is receiving PDB and initial offset is being applied to the auxiliary, then add:
“Less than 85 percent of the work used to figure (your/disabled worker's title and surname) public disability benefit was covered under Social Security. Because of this, we must (reduce/withhold) (your/his/her) family's Social Security disability benefits.”
(Same as 1.)
(Same as 9.)
(Same as 9.)