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).
[5]
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:
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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.
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Fill-ins:
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[1]
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Choice 1 -
Choice 2 -
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your
person's name, possessive, in format: John Smith's
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[2]
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Choice 1-
Choice 2-
Choice 3-
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A = MM/DD/YYYY
B = MM/DD/YYYY through MM/DD/YYYY
C = MM/DD/YYYY and MM/DD/YYYY
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[3]
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Amount of check(s)
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[4]
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Choice 1 -
Choice 2 -
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you are/are not
He/she is/is not
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[5]
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Choice 1 -
Choice 2 -
Choice 3 -
Choice 4 -
Choice 5 -
Choice 6 -
Choice 7 -
Choice 8 -
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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.
or
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).
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[6]
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or call your local Social Security office at (field office phone number is taken from
the DOORS).
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