BASIC (04-14)

NL 03001.050 Notice Issued When Requested Review of Prior Decision is Complete and we Determine if the Beneficiary or Recipient Is or Is Not Entitled to a Replacement Check

A. When to use notice

Use this language to inform the beneficiary or recipient that he or she is or is not entitled to check replacement based upon review.

B. Notice issued when review of prior decision is complete and we determine if the beneficiary or recipient is or is not entitled to a replacement check

As you asked, we have looked again at our decision not to replace [1] checks(s) dated [2], totaling $[3]. We have decided that [4] due a payment to replace the check(s).


If you have any questions, call us toll free at 1-800-772-1213 [6]. We can answer most questions over the phone. You can also write or visit any Social Security office.

The office that serves your area is:

  • District Office 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. If you plan to visit an office, you should call ahead to make an appointment. This will help us serve you more quickly.




Choice 1 -
Choice 2 -

person's name, possessive, in format: John Smith's


Choice 1-

Choice 2-

Choice 3-






Amount of check(s)


Choice 1 -
Choice 2 -

you are/are not
He/she is/is not


Choice 1 -

Choice 2 -

Choice 3 -

Choice 4 -

Choice 5 -

Choice 6 -

Choice 7 -

Choice 8 -

This is because you/he/she did not receive the original check(s).

You will soon receive a payment for $[amount of payment], which is the money you/he/she are/is due.

This is because the Department of Treasury found
that you/he/she signed the check(s).

This is because the Department of the Treasury cannot verify the signature on the check(s).

This is because the Department of the Treasury found that you/your representative put the check into an account.

This is because you received or bought things with money from the check(s).
NOTE: Examples of things include food, clothing, shelter, medical or dental treatment, etc.

This is because your representative payee bought things or gave you money from the check(s).

This is because you/he/she did not qualify for the original check(s) and should not have received it.

NOTE: Use this fill in when the Department of the Treasury determined the beneficiary or recipient cashed the check over a forged signature and SSA determined that the beneficiary or recipient was not entitled to the original check.

We lack documentation showing that we owe you any money based upon these check(s).



or call your local Social Security office at (field office phone number is taken from the DOORS).

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