Thank you for telling us about your plans to live briefly in (1) . We will send your checks to (2) . Please let us know if you decide that you want your checks sent elsewhere, or if you return to the United States.

(3) .

 

Your Responsibilities

If the information you have given us changes, it could affect your benefits. For this reason, it is important that you report changes to us right away.

We have enclosed a pamphlet, “Your Social Security Checks While You Are Outside the United States.” It will tell you what must be reported and how to report. Please be sure to read the part of the pamphlet which explains how work outside the United States could change your payments.

 

If You Have Any Questions

3901D

 

Enclosure:

SSA Pub. No. 05-10137

• •

  This letter is used when a beneficiary is moving to a foreign country for 6 months or less and requests his or her checks be mailed to an acceptable U.S. mailing address. The beneficiary must be under full retirement age and not under a disability.

• •

  The request for preparation is made on Form SSA-573, indicating the claim number, BIC, exhibit number, and the new (foreign) address. If the beneficiary's request indicates the individual has not yet left the old address, no address need be indicated on the SSA-573.

• •

  Request the beneficiary to complete and return Form SSA-21 if he or she has not already done so. The reviewing office must substitute its own return address on the Form SSA Pub. No. 05-10137 for the Office of International Operations.

   

Fill-ins:

1. (1) 

   country of the new (foreign) address

2. (2) 

   “the address shown on this letter.” OR “the financial institution you selected.”

3. (3) 

   if HI is involved, show caption Information About Medicare followed by
   
   MADCAP paragraph H96.

Refer to NL 00703.005E for 3901D text and fill-in.

• •

  Use Form SSA-2000-C2 (Universal Notice) and follow notice standards. Information for this notice will be shown on Form SSA-573.

• •

  When no address is furnished, the typist should take the address from the most current Form A101/EF101 or SSA-3926-C2.

• •

  The typist will include the necessary enclosures. The authorizer will request Form SSA-21, if needed.