We are writing to tell you about a check we are sending you (1) .

What We Will Pay and When

• •

  (2) due $(3) from (4) through (5) .

• •

  You will get a check for this amount around (6) .

If You Have Any Questions

3901C - Domestic

3901D - Foreign

Send when accrued benefits were withheld at the time benefits were awarded and the entire withheld amount is to be paid to the representative payee or directly to the beneficiary.

Fill-ins:

1. (1) 

   Leave blank in direct pay cases. Otherwise, show “for (full name of beneficiary)”, in the format, for June Sampson

2. (2) 

   In direct pay cases show “You are”. Otherwise, show “(first name of beneficiary) is” in the format, June is, if child; if adult, show “Mr.” or “Ms.” is, in format, Ms. Sampson.

3. (3) 

   Total amount of money due

4. (4) 

   First month, year accrued benefits were withheld, in the format of June 1992

5. (5) 

   Last month, year accrued benefits were withheld

6. (6) 

   Month, day, year payment is due, in the format of July 3, 1993

    

Optional Paragraph 3350A:

1. (1) 

   beneficiary's first name, if a child; if an adult, “Mr.” or “Ms.” last name

Use paragraph 3350A only when we pay the accumulated benefits to a payee and the type of payee code (TYP) is not SLM. Otherwise, omit the paragraph.

See NL 00703.005E. for 3901C and D text and fill-in.

Use Form SSA-L2000-C2 (Universal Notice) and follow the notice standards. Information for this notice will be shown on Form SSA-573.