We are writing to let you know that (1) saved $ (2) for (3) . They will send this money to you within the next 30 days.

 

What You Can Do

If you do not already have this money, or you do not receive it in the next 30 days, you should contact (4) . We are sending a copy of this letter to (5) . That way they will know that you may try to reach them. If you have any problems, please let us know.

 

Your Responsibilities

We may ask you to tell how you are managing this money as well as (6) regular monthly checks. For that reason you will need to keep track of all of the money you receive

for them .

If You Have Any Questions

3901C - Domestic

3901D - Foreign

cc: (7)

Send this letter when direct transfer of conserved funds has been authorized. In SSI cases the field office sends the letter.

Fill-ins:

1. (1) 

   name of former payee, in the format of Mark Jones or Johnson Nursing Home

2. (2) 

   amount of conserved funds in the format of 365.00

3. (3) 

   full name of beneficiary

4. (4) 

   name of former payee at address of former payee

5. (5) 

   name of former payee

6. (6) 

   first and last name of beneficiary, possessive in the format of John's, if a child; or adult

7. (7) 

   name of former payee

Use Form SSA-L2000-C2 (Universal Notice) in the PC and follow the notice standards. Information for this notice will be shown on Form SSA-573. Use FO letterhead for SSI cases. Copy of notice must be sent to former payee. (Fill-in #5.)