FORMAL PROTEST
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DATE:
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TO:
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FROM:
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Department of the Treasury
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Social Security Administration
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FMS - CCB
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(Local address)
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Exception Inquiries Section
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Appeals
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P.O. Box 51318
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Philadelphia, PA. 19115–6318
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Fax: 202-874-8447
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The following claimant is filing a formal protest on the forgery determination made
by your office.
CLAIMANT’S NAME ______________________________
CLAIMANT’S CURRENT ADDRESS ____________________________
SSN _____________________________
PROGRAM (check one): ____ SSI (Title XVI) or _____ SSA (Title II) _____
CHECK NUMBER __________ CHECK SYMBOL ____________
CHECK DATE__________ CHECK AMOUNT ____________
ADDITIONAL INFORMATION __________________________
CLAIMANT’S SIGNATURE ________________________________
Please contact the person named below if you have any questions.
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(Employee’s Name)
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___________________ |
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(Position)
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(Telephone)
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Attachments ( )
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