You asked us to hold back $ (1) from your checks each month because of you work. We will hold back this amount from your checks for (2) through (3) .

 

What We Will Pay And When

• •

  You will receive $ (4) around (5) .

• •

  After that, you will receive $ (6) each month.

   

Your Responsibilities

If you expect to earn more or less than $ (7) this year, please let us know right away. Any changes in the amount of money you earn may change your payments.

At the end of the year, we will send you a form called the “Annual Report of Earnings.” You will need it to report how much you actually earn for the year. After you report, we will make any necessary changes to your benefits because of the earnings.

 

If You Have Any Questions

3901C

• •

  After the reviewing office has approved the beneficiary's request to have his/her suspension prorated or deferred and the action has been processed through MADCAP, send this letter when no SMI is involved.

   

Fill-ins:

1. (1) 

   amount of benefits withheld

2. (2) 

   month/year withholding begins, e.g. January 1992

3. (3) 

   month/year withholding ends, e.g. May 1992

4. (4) 

   amount of next check

5. (5) 

   date of check e.g. June 3, 1992

6. (6) 

   amount of continuing monthly payment

7. (7) 

   amount of current earnings estimate

Refer to NL 00703.005E. for 3901C text.

Use SSA-L2000-C2 (Universal Notice) and follow the notice standards. Information for this letter will be shown on SSA-573.