SSN:

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

 

What We Plan To Do

Social Security payments will increase based on a rise in the cost of living. Although the amount you receive will increase, we must continue to take (3) percent out of the monthly payments.

 

What We Will Take Out

We will increase the amount we take out to $ (4) . You will receive a check for $ (5) each month beginning with the check you will receive around (6) .

 

If You Disagree With This Decision

If you disagree with any of these amounts, you should let us know within 60 days from the date you receive this letter.

 

If You Have Any Questions

3901C

• •

  This letter will be sent when we are withholding a set percentage of benefits and the amount we are withholding increases because of a cost of living increase.

• •

  Refer to NL 00703.005E. for 3901C text.

   

Fill-ins:

1. (1) 

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

2. (2) 

   case/civil action number

3. (3) 

   percentage of withholding

4. (4) 

   dollar amount being withheld after COLA

5. (5) 

   adjusted monthly benefit amount

6. (6) 

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