We are writing to tell you about a change in the Social Security checks you receive
for (1) . The rest of this letter will tell you why we are changing the checks, what
we will pay, and when the checks will (2) .
Why We Are Changing the Checks
What We Will Pay and When
You will receive $ (4) around (5) . This is the money (6) is due for (7). (8).
After that, you will receive $ (9) each month. (10).
If You Disagree With the Decision (ALSC04)
If you do not agree with this decision, you have the right to appeal. We will review
your case and look at any new facts you have. A person who did not make the first
decision will decide your case. We will review the parts of the decision that you
think are wrong and correct any mistakes. We may also review the parts of our decision
that you think are right. We will make a decision that may or may not be in your favor.
You have 60 days to ask for an appeal in writing.
The 60 days start the day after you receive 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 if you wait more than 60 days to ask for an appeal.
You can file an appeal with any Social Security office. You must ask for an appeal
in writing. Please use our "Request for Reconsideration" form, SSA-561. You may go
to our website at *F1 to find the form SSA-561. You can also contact us by phone,
mail, or come into an office to request the form. If you need help to fill out the
form, we can help you by phone or in person. (ALS020)
If You Want Help With Your Appeal1 (REPC01)
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 also are representatives who do not charge unless you win your appeal. Your
local 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. And if you hire a representative
who is eligible for direct pay, we will withhold up to 25 percent of any past due
benefits to pay toward the fee. (REP001)
If the information you have given us changes, it could affect the benefits. For this
reason, it is important that you report changes to us right away.
You should report any changes that are described in the pamphlet, “A Guide for Representative
Payees.” We sent you one of these pamphlets when you first became a payee. If you
need another pamphlet, you can get one from any Social Security office.2 Please be
sure to read the part of the pamphlet which explains how payments could change if
(11) has earnings from work.
If You Have Any Questions
CTDO - Domestic
3901D - Foreign
1 If the person lives outside the U.S. or has an attorney, omit this paragraph.
2 If the person lives outside the U.S., substitute “the office shown below,” for “any
Social Security office.”