We are writing to tell you about a change in (1) Social Security checks. Beginning (2) , we have figured your benefits (3) .
What We Will Pay And When
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You will receive $(4) around (5) . This is the additional money due for (6) .
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After that, you will receive $(7) each month.
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(Optional) 3317A
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We will still take your Medicare premium of $ (8) out of your regular monthly check.
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If you disagree with the decision
ALS020- Domestic
ALS020- Foreign
If you want help with your appeal1
3100E
If you have any questions
3901C - Domestic
3901D - Foreign
1 If the person has an attorney or lives outside the U.S. omit this paragraph.