We are writing to let you know that we will stop (1) Social Security benefits in
(2) . This is the benefit payment you would normally receive on (3) .
(4) benefits will stop because you have not returned the form, (5) . We need the information requested on this form to decide whether (6) can begin receiving benefits again.
(7)
Once we get this information, we will let you know whether
(8)
can begin receiving benefits again.
REF197
If You Have Any Questions
3901D
Enclosures:
Return Envelope - optional
SSA-21 - optional