We are sorry to learn of your recent loss. Please accept our sincere sympathy.

We are writing to let you know that your entitlement to benefits ended as of (1) . We based this on information that (2) died (3) .

We can pay (4) benefits only when you have a child in your care, under age 16 or disabled, who is entitled to Social Security benefits.

(If there is an overpayment, follow instructions in NL 00703.920 on what paragraphs to include.)

 

Other Social Security benefits

 

If you disagree with the decision¹

ALS020

 

If you have any questions

3901D

 

¹ If there is an overpayment, omit this paragraph.

• •

  Send when a child dies and benefits to the parent who had the child in care must be terminated.

• •

  Use paragraph 3923A when benefits to mother/father terminate.

• •

  Use paragraph 3923B when benefits to young spouse terminate.

• •

  Use ALS020 (except where there is an overpayment) and 3901D in all cases.

• •

  Refer to NL 00703.180 for ALS020 text. Refer to NL 00703.005E for 3901D text.

   

Fill-ins.

1. (1) 

   last month/year of entitlement e.g., May 1993

2. (2) 

   full name of deceased

3. (3) 

   month/year e.g., June 1993

4. (4) 

   mother’s, father's, or young spouse's

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