We are writing to let you know that we are stopping your Social Security benefits. Your representative payee will receive your last payment about (1) .

Why Your Payments Changed

Because you (2) treatment for (3) , we cannot pay you beginning (4) . Your payments will not begin again until you are both back in treatment and making progress for (5) months in a row.

We told you that we determined that (6) a contributing factor material to your disability. So, the law says you must go for treatment when it is available and make progress in your treatment or your payments will be stopped. The law also says that we cannot begin paying you right away even when you are once again going for treatment and making progress.

Your Payment Is Based On These Facts

(7) .

Things To Remember

• •

  If we must stop your payments for 12 months in a row because:

  — you do not go for the required treatment, or

  — you do not make progress in your treatment,

  you will have to file a new application to get Social Security again.

• •

  This decision refers only to your claim for Social Security payments.

• •

  This determination replaces all previous determinations for the above periods.

If You Disagree With The Decision

If you disagree with the decision, you have the right to appeal. We will review your case and consider any new facts you have.

• •

  You have 60 days to ask for an appeal.

• •

  The 60 days start the day after you get this letter. We assume you got this letter 5 days after the date on it unless you show us that you did not get it within the 5-day period.

• •

  You must have a good reason for waiting more than 60 days to ask for an appeal.

• •

  To appeal, you must fill out a form called “Request for Reconsideration.” The form number is SSA-561. To get this form, contact one of our offices. We can help you fill out the form.

Appeal In 10 Days To Keep Getting The Same Check

If you appeal within 10 days, you will continue to get the same check amount until we decide your case.

• •

  The 10 days start the day after you get this letter.

• •

  If you lose your appeal, you might have to pay back some or all of this money.

However, even if you appeal in 10 days, we may stop the check in (8) as shown on page 1 if both of the following are true:

• •

  Our new decision is the same as the one you appealed, and,

• •

  We send or give you a letter with our new decision in time to reduce the check.

   

If You Want Help With Your Appeal

You can have a friend, lawyer or someone else help you. There are groups that can help you find a lawyer or give you free legal services if you qualify. There are also lawyers who do not charge unless you win your appeal. Your local Social Security office has a list of groups that can help you with your appeal.

If you get someone to help you, you should let us know. If you hire someone, we must approve the fee before he or she can collect it. And if you hire a lawyer, we will withhold up to 25 percent of any past due benefits to pay toward the fee.

 

If You Have Any Questions

If you have any questions, you should call, write, or visit any Social Security office. If you do call or visit our office, please have this letter with you and ask for (9) . The telephone number is shown at the top of page 1.

Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly.

 

Fill-ins:

1. (1) 

   Date of last check payable (in the format “December 3, 1995”)

1. (4) 

   Date payments must be suspended, (in the format “December 1995”)

2. (5) 

   Number of sanction months to be served