It has been determined that (1) is under a disability within the meaning of the disability insurance provisions of
the Social Security Act.
This child is entitled to a monthly benefit of $ (2) beginning with the month of (3) . The next payment you receive will be in the amount of $ (4) and will represent payment for the month(s) of (5) . You will receive this payment (6) .
This claim will be reviewed from time to time to see if (7) is still eligible for benefits based on disability or blindness. When the claim is
reviewed, you will be contacted if there is any question as to whether (8) eligibility continues.
If (1) goes to work while (2) is still disabled, (3) may be entitled to a trial work period to test (4) ability to work. During this period (5) may work in as many as 9 months (which need not be consecutive) and still receive
disability benefit payments no matter how much (6) earns. After the trial work period is over, we will look at the work (7) did and we will decide whether (8) is still disabled.
However, the child is not entitled to a trial work period if:
(9) is entitled to a period of disability but not to disability cash benefits; or
(10) is receiving benefits for a second period of disability for which (11) did not have to complete a waiting period.
RESPONSIBILITIES OF PEOPLE RECEIVING DISABILITY BENEFITS
To prevent any incorrect payments, please notify us promptly if:
The child has already gone to work when you receive this notice; or if the child goes
to work in the future, regardless of how much he/she earns. Other events you need
to report are listed in the enclosed booklet entitled, “When You Get Social Security Disability Benefits...What You Need To Know.”
Since (1) condition may improve, we have scheduled a review for
(2) . At that time, you will be contacted if there is any question as to whether (3) condition remains severe. Also, a review of the claim may be necessary if (4) goes to work.
If we do get in touch with you, we may ask you to give us more information or to have
(5) take a medical examination. If we find (6) is still disabled, (7) benefits will continue. But, if the evidence obtained shows (8) is no longer disabled, the benefits will be stopped.
RESPONSIBILITIES OF PEOPLE RECEIVING DISABILITY
To prevent any incorrect payments please notify us promptly if:
(9) has already gone to work when you receive this notice, or
(10) goes to work (regardless of how much (11) earns), or
(12) doctor advises you that (13) condition has improved and that (14) is able to work.
Other events you need to report are listed in the enclosed booklet entitled, “When You Get Social Security Disability Benefits...What You Need To Know.”
Read the enclosed instructions for important information and events which affect the
payment of these benefits. You must notify the Social Security Administration promptly
when any one of these events occurs.
If You Disagree With The Decision
If You Have Any Questions
3901C - Domestic
3901D - Foreign
SSA Pub. No. 05-10153