We are writing to tell you that we are sending you a payment for $ (1) . We withheld this money from your benefits to pay your appointed representative(s).

We are sending you this money now because your appointed representative(s) told us that he or she would not charge you for services performed on your claim.

We are sending a copy of this letter to your appointed representative(s).

If You Have Any Questions

3901C - Domestic

3901D - Foreign

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  This letter will be sent in situations where the program service center was withholding retroactive benefits, but releases them to the beneficiary after the attorney indicates there will be no fee charged for services.

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

   

Fill-in:

1. (1) 

   amount of money withheld

Use Form SSA-L2000-C2 (Universal Notice) and follow notice standards. Information for this notice will be shown on Form SSA-573.