We are writing to let you know that (1) can no longer collect a fee from (2) monthly benefits for serving as (3) representative payee. If they were collecting a fee, they must stop doing so after (4) .

If You Have Any Questions

3765C

• •

  The FO will send this notice when the representative payee's authorization to collect a fee has been revoked.

• •

  Show the title of the officer and the name of the institution or entity. Do not show the name of such officer.

• •

  Refer to NL 00703.765 for 3765C text and fill-ins.

   

Fill-ins:

1. 1. 

   name of representative payee

2. 2. 

   your, name of beneficiary (possessive)

3. 3. 

   your, his, her

4. 4. 

   the last month/year in which the organization is permitted to collect a fee from this beneficiary.

The FO will send this notice. It may be reproduced on FO letterhead.