In title II cases, the FO is responsible for designating the notice. The PC is responsible
for all fill-ins. In title XVI the FO is responsible for the entire notice.
For change of payee situations: Send this letter when the unsuccessful applicant is
not the parent, person standing in place of the parent or legal guardian.
Social Security, Supplemental Security Income
If paragraph 3821A is requested:
If paragraph 3821B is requested:
SSA-623-OCR-SM (for domestic cases) or SSA-7161-OCR-SM (for foreign cases)
Use paragraph 3821A (“If You Have Saved Any Money” and “How To Pay Us Back” ) only if return of conserved funds is requested, i.e., to all former payees. Omit
this paragraph when this letter is sent to an unsuccessful payee applicant.
first name of beneficiary, possessive, in the format of John's, if child; if adult,
“Mr.” or “Ms.” last name possessive in format Mr. Smith's
actual claim number (Title II cases) or Social Security number (Title XVI), as appropriate.
Add paragraph 3100FC as the second paragraph under the caption, “How To Pay Us Back,” if a foreign address is involved. See NL 00703.100 for text.
Use paragraph 3821B if a final accounting is requested.
See NL 00703.005E. for 3901C and 3901D text and fill-in.