TN 35 (11-21)
Social Security Administration
Retirement, Survivors, and Disability Insurance
Claim Information
Miscellaneous Program Service Center
225 E. Oak Street
Central City, ST 00000
Date:
BNC: 21MS123J45678-A
JOHN G. BENEFICIARY
101 MAIN STREET
ANYTOWN, ST 00001
We have approved your request to withdraw your claim for all Social Security benefits.
Your Withdrawal Can Be Cancelled
If you change your mind and want to receive these benefits, you may cancel your withdrawal
by filing a written request with us. You have up to 60 days after the date of this
letter to ask for cancellation. After the 60 days are over, you have to file a new
application if you want to receive these benefits. You will not lose any benefits
if you cancel your withdrawal within the 60 days.
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.
Social Security Administration