BASIC (07-90)

NL 00725.007 NOA Letter with Payment Summary

Social Security Administration

Retirement, Survivors, and Disability Insurance

Notice of Award

                                                                                        Miscellaneous Program Service Center

                                                                                       225 E. Oak Street

                                                                                       Central City, ST 00000

                                                                                       Date:

                                                                                       Claim Number: 123-45-6789A

                

JOHN G. BENEFICIARY

101 MAIN STREET

ANYTOWN, ST 00001

          

You are entitled to monthly retirement benefits beginning November 1989.

             

What We Will Pay And When

  • You will receive $828.20 around February 10, 1989. This is the money you are due for November 1989 through January 1990.

  • You will receive $286 for February 1990 around March 3, 1990.

  • After that you will receive $286 each month.

  • Later on in this letter, we will show you how we figured these amounts.

               

Information About Medicare

You are entitled to Medicare hospital and medical insurance beginning November 1988.

                    

We will send your Medicare card in about 4 weeks. You should take this card with you when you need medical care. If you need care before you receive the card, use this letter as proof that you are covered by Medicare.

                     

The pamphlet we have enclosed, “Basic Facts About Medicare and Other Health Insurance,” gives you more information about the Medicare program.

Other Social Security Benefits

The benefits described in this letter is the only one you can receive from Social Security. If you think you might qualify for another kind of Social Security benefit in the future, you will have to file another application.

                               

Do You Think We Are Wrong?

If you think we are wrong, you have the right to appeal. We will correct any mistakes and will look at any new facts you have. A person who did not make the first decision will decide your case.

          

  • You have 60 days to ask for an appeal.

  • The 60 days start the day after you get this letter.

  • You must have a good reason if you wait more than 60 days to ask for an appeal.

          

Your Responsibilities

Your benefits are based on the information you gave us. If this information changes, it could affect your benefits. For this reason, it is important that you report changes to us right away.

        

We have enclosed a pamphlet, “Your Social Security Rights and Responsibilities.” It tells you what you must be reported and how to report. Please be sure to read the part of the pamphlet which explains how work could changes your payments.

                        

If You Have Any Questions

If you have any questions, you may call us at 1-800-2345-SSA. We can answer most questions over the phone. You can also write any Social Security office. The office that serves your area is located at:

                                               Street address

                                               City, State Zip

If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment at the office. This will help us serve you more quickly when you arrive at the office.

                    

                                                                                 Gwendolyn S. King

                                                                                 Commissioner

                                                                                      of Social Security

              

Enclosure(s):

Pub 05-10014

PAYMENT SUMMARY

       

Your Payment of $828.20

Here is how we figured your first payment:

    Benefits due for November 1989 through
   January 1990 including the cost of living
    increase, less monthly rounding of benefits          . . . . . . . . . . . . . . . . . . . . . .   $ 941.60

   Amount we subtracted because of:

       o    premiums for medical insurance
             through January 1990                . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .     81.50

       o    Additional premium due
            one month in advance                . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .      31.90

This equals the amount of the first payment . . . . . . . . . . . . . . . . . . . . . . . . . . .     $ 828.20

           

Your Regular Monthly Payment

Here is how we figured your regular monthly payment beginning February 1990:

   You are entitled to a monthly benefit of . . . . . . . . . . . . . . . . . . . . . . . . . . . .     $ 318.70

    Amounts we subtracted because of:

      o   premium for medical insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .       31.90

           This equals   . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   286.80

      o   rounding (we must round down to a whole dollar) . . . . . . . . . . . . . . . . .            .80

   This equals the amount of the regular monthly payment . . . . . . . . . . . . . . .        $ 286.00


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900725007
NL 00725.007 - NOA Letter with Payment Summary - 06/09/2003
Batch run: 01/27/2009
Rev:06/09/2003