We are writing to you about the enclosed court order number (1) concerning (2) responsibility for child support, alimony or court ordered victim restitution.

What We Plan To Do

If the claim is approved, we may have to take money out of (3) Social Security payments to satisfy the court order. This means that although the monthly benefit amount would be the same, we could reduce the monthly payments to collect the money for child support, alimony, or court ordered victim restitution.

If the claim is approved and we decide we have to reduce the payments, we will write and let you know how much money we will take out each month and when this will happen.

If You Disagree

If you disagree with the decision of (4), you will need to contact them directly, or have a lawyer do this for you. They can be contacted at:

• •

  (5)

If You Have Any Questions

3901C

Enclosure:

Copy of Court Order

• •

  This notice is sent by the office which initially receives the garnishment order when the office determines that there is a claim pending. (GN 02410.210A.4.). The notice must be sent within 15 days of service.

• •

  Refer to NL 00703.005E for 3901C text and fill-ins.

Fill-ins:

1. (1) 

   case/civil action number

2. (2) 

   beneficiary's full name, possessive in format: Robert L. Smith's/ “your”

3. (3) 

   beneficiary's title and last name, possessive in format: Mr. Smith's/ “your”

4. (4) 

   name of court or other public official/agency in format: the Baltimore County Court

5. (5) 

   address of court or public official/agency