We are writing to let you know that we will stop (1) Social Security benefits in

(2) . This is the benefit payment you would normally receive on (3) .

(4) benefits will stop because you have not returned the form, (5) . We need the information requested on this form to decide whether (6) can begin receiving benefits again.

(7)

Once we get this information, we will let you know whether (8) can begin receiving benefits again.

 

REF197

 

If You Have Any Questions

3901D

 

Enclosures:

Return Envelope - optional

SSA-21 - optional

This notice is used when a beneficiary has not returned the Form SSA-7161-OCR-SM, SSA-7162-OCR-SM and/or SSA-21 as requested. Refer to NL 00703.005E. for 3901D text and fill-ins.

 

Fill-ins:

1. (1) 

   your, full name of beneficiary - possessive

2. (2) 

   month/year; e.g., July 1992

3. (3) 

   month/day/year; e.g., August 03, 1992

4. (4) 

   Your, His, Her, Their

5. (5) 

   name of form(s) (SSA-7161–OCR-SM, Report to United States Social Security Administration), (SSA-7162–OCR-SM, Report to United States Social Security Administration) and/or (SSA-21, Supplement to Claim of Person Outside the United States)

6. (6) 

   you, he, she, they

7. (7) 

   (choice 1) We have enclosed a copy of the SSA-21 with this letter. Please complete this form and return it to is in the enclosed envelope.

   (choice 2) NULL

8. (8) 

   you, he, she, they