Required – E4036A
We plan to reduce (1) Social Security payments to (2) in (3) because (4) .
Fill-ins:
(1) |
a. your
b. [Number holder’s name (possessive)]
|
(2) |
[amount] |
(3) |
[month/year] |
(4) |
a. of a change to your earnings record
b. we removed earnings
c. we reduced earnings
d. your employer filed a corrected W-2 form
e. the Internal Revenue Service reported a change to your earnings
f. [null (optional dictated language)]
|
Optional – E4036B
The chart below shows the changes in (1) earnings record that caused us to decrease (2) benefit amount:
Fill-ins:
(1) |
a. your
b. [Number holder’s name (possessive)]
|
(2) |
a. your
b. his
c. her
|
Optional – E4036C
Year New Earnings Amount Old Earnings Amount
Optional – E4036D
(1) (2) (3)
Fill-ins:
(1) |
[year] |
(2) |
[new earnings amount] |
(3) |
[old earnings amount] |
|
(prompt for another earnings line) |
Optional – E4036E
Due to this change, (1) new reduced benefit amounts before any deductions are:
Fill-ins:
(1) |
a. your
b. his
c. her
|
Optional – E4036F
Effective Date New Benefit Amount Old Benefit Amount
Optional – E4036G
(1) (2) (3)
Fill-ins:
(1) |
[month/year (effective date)] |
(2) |
[amount (new benefit amount)] |
(3) |
[amount (old benefit amount)] |
|
(prompt for another benefit amount line) |
Required – E3123.1A
If You Disagree With The Decision
Please tell us within 101 days of the date of this letter if you disagree with the decision. You will also
need to give us any proof you have to show that what we were told is wrong.
If you let us know within 101 days that you disagree with the decision, we will not reduce your checks. We will
continue to pay you while we review your case to see if you are right. However, if
you are wrong we will ask you to pay back any money you received that was not due.
If we do not hear from you within 101 days, we will reduce your checks. We will send you another letter at that time with
more information about our action.
1For foreign beneficiaries, 30 days.
Required – CTDO or 3901D
If You Have Any Questions
3901C - Domestic
3901D – Foreign
For 3901C and 3901D text and fill-ins refer to NL 00703.005E.