BASIC (07-90)

NL 00725.009 Withdrawal Notice

Social Security Administration

Retirement, Survivors, and Disability Insurance

Claim Information

                                                                                       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

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.

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