FORMAL PROTEST
         
            
               
                  
                  
               
               
                  
                  
                     
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                     |   | DATE:                | 
                  
                     
                     | TO: | FROM: | 
                  
                     
                     | Department of the Treasury | Social Security Administration | 
                  
                     
                     | FS - CCB | (Local address) | 
                  
                     
                     | Exception Inquiries Section |   | 
                  
                     
                     | Appeals |   | 
                  
                     
                     | P.O. Box 51318 |   | 
                  
                     
                     | Philadelphia, PA. 19115–6318 |   | 
                  
                     
                     | Fax: 202-874-8447 |   | 
               
            
          
         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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                     | Attachments ( ) |   |