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:

 

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.

• •

  The family will have 60 days to ask for an appeal.

• •

  The 60 days will start the day after the family receives the next letter.

   

If You Have Any Questions

3901C

 

Fill-ins:

1. (1) 

   reduce/withhold

2. (2) 

   your/full name of disabled worker, possessive

3. (3) 

   you/he/she

4. (4) 

   receive/receives/received an increase in

5. (5) 

   workers' compensation/public disability/black lung/federal employees compensation

6. (6) 

   reduced/withheld

7. (7) 

   month and year that offset should have begun or changed

8. (8) 

   name of organization paying the benefit

9. (9) 

   your/disabled worker's title and surname, possessive

10. (10) 

    (Same as 5.)

11. (11) 

    amount(s) of WC, PDB, FECA or BL payments

12. (12) 

    effective month(s) and year(s) of WC, PDB, FECA or BL payments

13. (13) 

    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.”

14. (14) 

    (Same as 1.)

15. (15) 

    (Same as 9.)

16. (16) 

    (Same as 9.)

17. (17) 

    your/his/her