Send this notice when a single check (one check only) is being issued to pay any retroactive increase, after which the benefits are in conditional or suspense status.

We are writing to tell you about a change in Social Security benefits. Beginning (1) , we have refigured your benefits (2) .

What We Will Pay And When

• •

  You will receive $ (3) around (4) . This is the money you are due for (5) .

• •

  You still will not receive regular monthly checks because (6) . If we can send you money in the future, your new monthly payment will be $ (7) .

If You Disagree With the Decision (ALSC04)

If you do not agree with this decision, you have the right to appeal. We will review your case and look at any new facts you have. A person who did not make the first decision will decide your case. We will review the parts of the decision that you think are wrong and correct any mistakes. We may also review the parts of our decision that you think are right. We will make a decision that may or may not be in your favor.

• •

  You have 60 days to ask for an appeal in writing.

• •

  The 60 days start the day after you receive this letter. We assume you got this letter 5 days after the date on it unless you show us that you did not get it within the 5-day period.

• •

  You must have a good reason if you wait more than 60 days to ask for an appeal.

You can file an appeal with any Social Security office. You must ask for an appeal in writing. Please use our "Request for Reconsideration" form, SSA-561. You may go to our website at *F1 to find the form SSA-561. You can also contact us by phone, mail, or come into an office to request the form. If you need help to fill out the form, we can help you by phone or in person. (ALS020)

If You Want Help With Your Appeal1 (REPC01)

You can have a friend, representative, or someone else help you. There are groups that can help you find a representative or give you free legal services if you qualify. There also are representatives who do not charge unless you win your appeal. Your local Social Security office has a list of groups that can help you with your appeal.

If you get someone to help you, you should let us know. If you hire someone, we must approve the fee before he or she can collect it. And if you hire a representative who is eligible for direct pay, we will withhold up to 25 percent of any past due benefits to pay toward the fee. (REP001)

If You Have Any Questions

3901C - Domestic

3901D - Foreign

1 If the beneficiary has an attorney or lives outside the U.S., omit this paragraph.

1. 1. 

   effective date of change, month/year

2. 2. 

   use reason A - M or use dictated language

   (a)

   to correct the previous calculation.

   (b)

   to give credit for additional earnings.

   (c)

   to increase the rate because the benefits of another person have been terminated.

   (d)

   to decrease the rate because another person is entitled to benefits.

   (e)

   to increase the rate because a period of disability has been established.

   (f)

   to give credit for months of entitlement before full retirement age (62) for which less than the full benefit was paid.

   (g)

   to give credit for months of entitlement before full retirement age for which benefits were paid based on caring for a child who was entitled to benefits.

   (h)

   to give credit for months your deceased spouse was entitled to, but not paid, full benefits between age 62 and 65.

   (i)

   to give credit for months when you were at least full retirement age and did not receive a retirement benefit because you were working.

   (j)

   because of a special provision of the law. This special provision increases benefits for people who have worked under Social Security for many years at relatively low earnings.

   (k)

   to give credit for additional earnings and also to give credit for months after 1970 when you were at least full retirement age and did not receive a retirement benefit because you were working.

   (l)

   to decrease the benefits based on your amended annual report of earnings which shows you worked in fewer months after full retirement age than you had originally reported.

   (m)

   to give credit for months your deceased spouse was at least 65 and did not receive a retirement benefit because of work.

3. 3. 

   amount of payment

4. 4. 

   date of check, format “May 20, 1987”

5. 5. 

   first month is first month of increase; last month is last month used to figure PMA; format “January 1986 through May”; the year should be omitted if only 1 calendar year is involved.

6. 6. 

   give reason for non-payment, for example “of your earnings”

7. 7. 

   current monthly payment amount

Refer to NL 00703.005E for CTDO and 3901D text and fill-ins. Refer to NL 00703.180 for ALSC04 and ALS020 text. Refer to NL 00703.100 for REPC01 and REP002 text.