TN 30 (03-96)

NL 00703.700 Withdrawal — Repayment — NH

Document Identifier for Word Processor: E3700

A. Exhibit letter

If we approve your request for withdrawal of your application for (1) benefits, it would have the effect of completely cancelling your previous claim. All payments which you received based on the previous claim must be repaid before we can approve your request for withdrawal.

You became entitled to monthly benefits of $ (2) beginning (3) . The last monthly payment you received was for (4) . This means that you received a total of $ (5) which you must repay.


3700AHowever, you will not have to send us this entire amount. If we approve your withdrawal, you will become entitled to (1) benefits based on your new application. Your new claim will be effective (2) at the rate of
$ (3) . We will use $ (4) benefits accrued on your claim to reduce the amount you must repay.

If you wish to withdraw your claim, send a certified check or money order for $ (6) , made payable to the Social Security Administration. Mail your payment to us using the enclosed refund envelope. Please do not mail your payment to the address at the top of this notice. Be sure to write the Social Security claim number listed at the top of this notice on the check or money order.

3700BIf you decide that you do not want to withdraw your claim, or if you have any questions, call us toll-free at 1-800-772-1213, or call your local Social Security office at (FO telephone number).
 We can answer most questions over the phone. You can also write or visit any Social Security office. The office that serves your area is located at:

District Office Address
City, ST ZIP

 If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.



Refund envelope

B. Requesting instructions

  • The request for this letter may be made on Form SSA-573 or SSA-559 by the claims authorizer or by the benefit authorizer. The authorizer will furnish the fill-in information and, if necessary, any additional paragraphs that may be needed.

  • Use 3700A when a new claim is filed with the withdrawal request and benefits will be paid.

  • Use 3700B in all cases.



    1. Type of benefits, e.g. “retirement” or “disability”

    2. Amount of monthly benefits

    3. Month/Year monthly benefits began

    4. Month/Year of last monthly payment

    5. Amount of benefits received

    6. Amount of benefits that must be repaid

    Paragraph 3700A:

    1. Type of benefits, e.g. “retirement” or “disability”

    2. Month/Year benefits will be effective

    3. Amount of monthly payment

    4. Amount of benefits accrued

C. Typing instructions

Use Form SSA-L2000-C2. The typist should enclose a self-addressed envelope with the notice and the claim number should be written on the inside of the envelope below the flap.

To Link to this section - Use this URL:
NL 00703.700 - Withdrawal -- Repayment -- NH - 07/18/2014
Batch run: 07/18/2014