We are writing to let you know that we have made some changes in your benefits. We
made these changes based on the death of (2) in (3).
This letter will also tell you what to do if you want survivor’s benefits.
What We Will Pay And When
Your regular monthly benefit is (4) starting in (5). This is the benefit due you based on your own record.
You should receive your payment about (6). After that, you will receive your payments on or about the (7) of each month.
Changes in your benefits
You are no longer entitled to (8) benefits. We stopped your (9) benefits effective (10).
You will still get (11) benefits on your own record.
If You Want Survivors Benefits
You may be able to get permanently reduced (12) benefits. The benefit rate is reduced by a specified percentage for each month you
are entitled before full retirement age (FRA). For example, if you were born between
1945 and 1956, the benefit reduction would be about 0.396 percent for each month you
are entitled before your FRA. If the deceased worker received retirement benefits
before FRA, the maximum survivor’s benefit is limited to the higher amount that the
deceased worker would have received if still alive or 82.5 percent of the deceased
worker’s unreduced benefit.
Because of this limit, delaying receipt of reduced (8) benefits will not necessarily increase the monthly benefit amount payable. We will
review your election in item 3 on the Certificate of Election to make sure that the
month selected maximizes your benefit amount.
If you wish to receive permanently reduced benefits, please complete the (9) and return it to us in the self-addressed envelope provided. If you need help completing
the certificate, your local Social Security office will be happy to help you.
What we will pay and when
Your regular monthly benefit is $(10), beginning (11). This is the benefit due you based on your own Social Security record. Your Social
Security number is (12).
You should receive your first check about (13). If you were born between 1945 and 1956, we reduce your benefit by 0.396 percent
for each month you are entitled before your full retirement age (FRA). If you were
born in a different year, a different reduction rate applies. If the worker started
receiving retirement benefits before his or her FRA, we cannot pay the full benefit
amount on his or her record. We must limit the maximum survivor's benefit to the higher
the amount that he or she would have received if still alive, or
82.5 percent of his or her unreduced benefit.
Due to this limit, a delay in taking your survivor's benefits will not always increase
the monthly benefit we can pay to you.
For more information, please visit our online "Survivors Planner" at www.SocialSecurity.gov.
Other Social Security benefits
If the worker's death occurred before FRA or within one year past FRA, and he or she
could not work due to disability, you may be able to get a higher benefit on his or
her record. You have to file a separate application for the higher benefit by (15).
If you were married before, you may be able to get a higher benefit on your prior
spouse's record. Please file an application to learn if you are eligible for these
If you disagree with the decision
If you want help with your appeal
If you have any questions
3901C - (CTDO UTI) - Domestic
3901D - Foreign