We are writing to tell you that [1] due a payment to replace the check(s) dated [2]
totaling $[3]. [4]
[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 -
Choice 3-
Choice 4-
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You are
You are not
Name of payee is
Name of payee is not,
NOTE: Choice 3 and 4 correct format: John Smith is or John Smith is not
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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 -
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
payee 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/them.
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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[5]
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Use this paragraph ONLY when the person is not entitled to a replacement check:
If you disagree with our decision, you can ask us to look at the information that
we have about the check(s) again. A person who did not look at this information the
first time will review it. We will also consider any new facts you have. Contact us
right away, if you want us to review this information.
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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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