TN 74 (07-18)
Document Identifier for Aurora: E3700
If we approve (#1) request to withdraw (#2) claim for (#3), we will completely cancel
We can approve the withdrawal only if (#4) all the money paid from the claim. This
includes any money we withheld from (#5) benefits.
If (#6) withdrawal request includes Medicare, (#7) must repay any costs for Medicare
Part A (Hospital Insurance) services (#8) received.
What (#9) must repay
(#10) $ (#11)
$ (#1) (#2)
(#14) $ (#15)
This means (#16) must repay us a total of $ (#17) before we can withdraw the claim.
However, 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 (#1) claim, (#2) must send us a check or money order for $
(#3). Make the check or money order payable to the Social Security Administration.
Be sure to write the Social Security Claim Number on (#4) payment.
Please mail (#5) payment to us using the enclosed refund envelope. Do not mail (#6)
payment to the address at the top of this notice.
If 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
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:
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 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 E3700A only when a new claim is filed with the withdrawal request and benefits
will be paid.
Use E3700.1, E3700B, and E3700.2 in all cases.
your/Requestor’s Full Name (possessive)
your/his/her/Beneficiary’s Full Name (possessive)
A = retirement benefitsB = disability benefitsC = survivor’s benefitsD = retirement benefits and MedicareE = disability benefits and MedicareF = survivor’s benefits and MedicareG = Medicare
you repay/he repays/she repays
A = nullB = The cost of the Medicare Part A services you received isC = The cost of the Medicare Part A services he received isD = The cost of the Medicare Part A services she received is
A = null (if repayment is for Medicare only)B = You received, or will receive, Social Security benefits of:C = He received, or will receive, Social Security benefits of:D = She received, or will receive, Social Security benefits of:
A = null (If repayment is for Medicare only)B = (Activate UTI E3700.1A Chart UTI)
Benefit month A/B, MM/YYYY, MM/YYYYA = MM/YYYYB = MM/YYYY through MM/YYYY
Another Line? (Y/N)/NULL
A = NULLB = Amount already returned
Amount refunded or NULL
Total amount to be repaid
Type of benefits, e.g. “retirement” or “disability”
Month/Year benefits will be effective (MM/YYYY)
Amount of monthly payment
Amount of benefits accrued
Addressee zip code (5 digits)
Addressee zip+4 (4 digits)
Telephone area code (3 digit)
Phone exchange (3 digit)
Phone number (4 digit)
Local office address line 1
Local office address line 2
Local office address line 3
Local office city and state
Local office zip code (5 digits)
Zip+4 of local office (4 digits)
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