We have decided that it would be best for ___(1)___ if we continue to pay ___(2)___ Special Veterans Benefit (SVB) payments to ___(3)___.

If You Disagree With The Decision

If you think you should get ___(4)___ payments or that someone else should help manage ___(5)_ payments, you have the right to appeal this decision. A person who did not make the first decision will decide your case. We will review the decision with which you disagree and will look at any new facts you have. We may also review those parts with which you agree and may make them unfavorable or less favorable to you.

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  You have 60 days to ask for an appeal.

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  You must put the request for an appeal in writing.

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  The 60 days start the day after you receive this letter.

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

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  You may make your request through any U.S. Social Security office, United States Embassy or consulate, or the U.S. Veterans Affairs Regional Office in Manila. Or, you may write to us at the address shown at the top of this letter.

Please read the enclosed leaflet, “Your Right to Question the Decision Made on Your Social Security Claim”. It contains more information about an appeal.

[Optional Domestic Paragraph-Domestic Addressee]

If You Have Questions or Need Help

If you have any questions, you may call, write or visit any Social Security office. If you call or visit an office, please have this letter with you. The telephone number for our office is shown at the top of this letter. 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 the office.

[Optional Foreign Paragraph-Foreign Addressee]

If You Have Questions or Need Help

If you have questions, you should contact one of the offices shown below. You may also write to us at the address shown at the top of this letter. However, if you call or visit an office, please have this letter with you.

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  If you live in Canada, contact any U.S. Social Security office.

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  If you live in Guam, Puerto Rico, American Samoa or the U.S. Virgin Islands, you should contact the nearest U.S. Social Security office.

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  If you live in Mexico, contact any U.S. Social Security office or the nearest United States Embassy or consulate.

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  If you live in the Philippines, please call 523-1001 extension 2516 or 2645 from 8:00 am to 2:00p.m. or write/visit SSA Division, U.S. Department of Veterans Affairs, American Embassy, 1131 Roxas Boulevard, 0930 Manila.

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  If you live in any other country, you should contact the nearest United States Embassy or consulate.

Notice Fill-ins:

1. (1) 

   ([beneficiary's full name])

2. (2) 

   (his) or (her)

3. (3) 

   (him) or (her) or ([name of representative payee]) or ([name of institution]) or ([name of entity])

4. (4) 

   (Mr.) or (Ms.) ([beneficiary's last name]), possessive

5. (5) 

   (his) or (her)

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  The CPS is responsible for sending this notice.

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  If a domestic address is involved, select Optional Domestic Paragraph.

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  If a foreign address is involved, select Optional Foreign Paragraph.

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  Enclose Pub. 05-10058, “Your Right to Question the Decision Made on Your Social Security Claims”.