SSN:

We are writing to tell you about a change in court order number (1) concerning (2) responsibility for child support, alimony, or court ordered victim restitution, and how it affects Social Security payments.

 

What We Plan To Do

(3) has asked us to take a different amount of money out of the monthly payments. We will now (4) the monthly payments beginning (5) because of this change in the order.

 

What We Will Take Out

We will take out $ (6) from each monthly payment to collect the amount owed. You will receive a check for $ (7) each month beginning with the check you will receive around (8) .

 

If You Disagree With This Decision

If you disagree with the decision of (9) , you will need to contact them directly, or have a lawyer do this for you. They can be contacted at this address:

 

•  

  (10)

   

If You Have Any Questions

3901C

• •

  This notice will be sent when the court either increases or decreases the money amount being withheld by issuing an amended garnishment order.

• •

  Refer to NL 00703.005E. for 3901C text.

   

Fill-ins:

1. (1) 

   case/civil action number

2. (2) 

   “your”/beneficiary's full name, possessive in format: Robert L. Smith's

3. (3) 

   name of court or public official/agency in format: The Baltimore County Court

4. (4) 

   “decrease”/“increase”

5. (5) 

   month/year (MM/YYYY) change is effective

6. (6) 

   dollar amount being withheld

7. (7) 

   adjusted monthly benefit amount

8. (8) 

   month/day/year (MM/DD/YYYY) new payment will arrive

9. (9) 

   name of court or public official/agency, in the same format as fill-in #2

10. (10) 

    address of court or public official/agency