BASIC (05-11)

NL 00720.255 PEN Penalty

PEN001 PENALTY DEDUCTED FROM BENEFITS DOMESTIC CASES (W23)

(Requested)

Caption: A Penalty Will Be Deducted From Payments

We are writing to you about a  (1)  penalty that will be held back from  (2)  benefits. We told you earlier that this penalty would be held back because you did not report  (3)   (4)  earnings to us before April 15,  (5)  and did not give us a good reason for being late.

Fill-in values:

Fill-in (1) - Systems Generated

Amount

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Choice 4: Beneficiary's Name possessive

Fill-in (4) - Systems Generated

CCYY

Fill-in (5) - Systems Generated

CCYY

PEN016 HEALTH PLAN PREMIUM AMOUNT INCLUDES A PENALTY (H28)

(System Generated)

Caption: Information About Health Plan Premiums

This amount includes a penalty for  (1)  Medicare Prescription Drug Plan Premium.

Fill-in values:

Choice 1: your

Choice 2: his

Choice 3: her

PEN024 PENALTY DEDUCTED FROM BENEFITS FOREIGN CASES (W24)

(Requested)

Caption: A Penalty Will Be Deducted From Payments

We are withholding  (1)  from  (2)  monthly benefits. This is a penalty because  (3)  did not give us  (4)  report of work on time.

Fill-in values:

Fill-in (1) Requested As A Money Amount In Format $$$$$.¢¢

Amount of penalty

Fill-in (2) Systems Generated

Choice 1: your

Choice 2: Beneficiary's name possessive

Fill-in (3) Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (4) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

PEN025 PENALTY PROPOSED/GOOD REASON REQUESTED DOMESTIC CASES (W25)

(Requested)

Caption: A Penalty Will Be Deducted From Payments

 (1)  to let us know how much money  (2)  each year. To do this,  (3)  must give us a report of each year's earnings within 3 ½ months after the end of the taxable year. Since  (4)  did not do this for  (5) , we will withhold  (6)  more from  (7)  benefits as a penalty. We will do this unless  (8)  can show that  (9)  had a good reason for not giving us the report on time.

If  (10)   (11)  had a good reason for not reporting your earnings before  (12) , please let us know within 30 days of the date of this letter. If  (13)  had a good reason for not reporting, we will not withhold the additional money. Otherwise, we will send  (14)  another letter to tell  (15)  when we will start withholding the money.

Fill-in values:

Fill-in (1) Systems Generated

Choice 1: You need

Choice 2: Beneficiary's name needs

Fill-in (2) Systems Generated

Choice 1: you earn

Choice 2: he earns

Choice 3: she earns

Fill-in (3) Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (4) Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (5) Requested as a date shown below

Year CCYY

Fill-in (6) Requested as Money amount in format $$$$$.¢¢

Amount

Fill-in (7) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (8) Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (9) Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (10) Systems Generated

Choice 1: you think

Choice 2: Beneficiary's name thinks

Fill-in (11) Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (12)

MM/DD/CCYY

Fill-in (13) Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (14) Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (15) Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

PEN026 PENALTY PROPOSED/GOOD REASON REQUESTED FOREIGN CASES (W26)

(Requested)

Caption: A Penalty Will Be Deducted From Payments

 (1)  to let us know when  (2)  more than 45 hours in a month.  (3)  must let us know about this work before  (4)   (5)  third Social Security check after returning to work. Since  (6)  did not do this, we will withhold  (7)  more from  (8)  benefits as a penalty. We will do this unless  (9)  can show that  (10)  had a good reason for not giving us the report on time.

If  (11)   (12)  had a good reason for not reporting  (13)  work on time, please let us know within 30 days of the date of this letter. If  (14)  had a good reason for not reporting, we will not withhold the additional money. Otherwise, we will send  (15)  another letter to tell  (16)  when we will start withholding the money.

Fill-in values:

Fill-in (1) Systems Generated

Choice 1: You need

Choice 2: Beneficiary's name needs

Fill-in (2) Systems Generated

Choice 1: you work

Choice 2: he works

Choice 3: she works

Fill-in (3) Systems Generated

Choice 1: You

Choice 2: He

Choice 3: She

Fill-in (4) Systems Generated

Choice 1: you receive

Choice 2: he receives

Choice 3: she receives

Fill-in (5) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (6) Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (7) Requested as Money amount in format $$$$$.¢¢

Amount of penalty

Fill-in (8) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (9) Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (10) Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (11) Systems Generated

Choice 1: you think

Choice 2: Beneficiary's name thinks

Fill-in (12) Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (13) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (14) Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (15) Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (16) Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

PEN027 PENALTY TO BE DEDUCTED FROM FUTURE BENEFITS DOMESTIC CASES (W27)

(Requested)

Caption: A Penalty Will Be Deducted From Payments

When we start to pay  (1)  again, we will withhold  (2)  more from  (3)  benefits as a penalty because  (4)  did not let us know how much  (5)  earned in  (6)  within 3 ½ months after the end of the taxable year.

Fill-in values:

Fill-in (1) Systems Generated

Choice 1: you

Choice 2: Beneficiary's name

Fill-in (2) Requested as Money amount in format $$$$$.¢¢

Amount of penalty

Fill-in (3) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (4) Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (5) Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (6) Request As A Date in Format Shown Below

CCYY format

PEN028 PENALTY TO BE DEDUCTED FROM FUTURE BENEFITS FOREIGN CASES (W28)

(Requested)

Caption: A Penalty Will Be Deducted From Payments

When we start to pay  (1)  again, we will withhold  (2)  more from  (3)  benefits as a penalty. This is because  (4)  did not let us know that  (5)  started working before  (6)  received  (7)  third Social Security check after beginning to work.

Fill-in values:

Fill-in (1) Systems Generated

Choice 1: you

Choice 2: Beneficiary's name

Fill-in (2) Requested as Money amount in format $$$$$.¢¢

Amount of penalty

Fill-in (3) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (4) Systems Generated

Choice 1: you

Choice 2: he

Ch