Social Security Administration
Retirement, Survivors, and Disability Insurance
JOHN G. BENEFICIARY
101 MAIN STREET
ANYTOWN, ST 00001
What We Will Pay And When
Your monthly benefit is $500.00 beginning 03/2005.
Based on the information you have provided us, we can grant good cause for not satisfying
the outstanding warrant beginning 01/2005 because you are residing in a long-term
Other Social Security Benefits
The benefits described in this letter are the only ones to which you are entitled
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.
If You Disagree With The Decision
If you disagree with this decision, you have the right to appeal. We will review your
case and consider any new facts you have. A person who did not make the first decision
will decide your case. We will correct any mistakes. We will review those parts of
the decision which you believe are wrong and will look at any new facts you have.
We may also review those parts which you believe are correct and may make them unfavorable
or less favorable to you.
You have 60 days to ask for an appeal.
The 60 days start the day after you get this letter. We assume you got this letter
5 days after the date on it unless you show us that you did not get it within the
You must have a good reason for waiting more than 60 days to ask for an appeal.
You have to ask for an appeal in writing. We will ask you to sign a Form SSA-561-U2,
called "Request for Reconsideration." Contact one of our offices if you want help.
Please read the enclosed pamphlet, "Your Right to Question the Decision Made on Your
Social Security Claim." It contains more information about the appeal.
If You Want Help With Your Appeal
You can have a friend, representative, or someone else help you. There are groups
that can help you find a representative or give you free legal services if you qualify.
There are also representatives who do not charge unless you win your appeal. Your
Social Security office has a list of groups that can help you with your appeal. If
you get someone to help you, you should let us know. If you hire someone, we must
approve the fee before he or she can collect it.
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
We invite you to visit our website at www.socialsecurity.gov on the Internet to find
general information about Social Security. If you have any specific questions, you
may call us toll-free at 1-800-772-1213, or call your local Social Security office
at 1-610-433-3237. We can answer most questions over the phone. If you are deaf or
hard of hearing, you may call our TTY number, 1-800-325-0778. You can also write or
visit any Social Security office. The office that serves your area is located at:
41 N 4TH ST
ALLENTOWN, PA 18102
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. This will help us serve you more quickly when you arrive at
NOTE: The general referral paragraph and the appropriate signature are also required for
the notice. See NL 00601.040 for additional paragraphs required on post-entitlement notices; e.g., overpayment
or underpayment paragraphs, etc. See NL 00601.003 for name and signature requirements on notices.