We are writing to tell you about extra money we are sending you.

 

What We Will Pay and When

• •

  You are due $(1) . This is the money that the last representative payee saved for you and returned to us.

• •

  You will get this money over a period of months.

• •

  We will send you $(2) each month in addition to the regular check you already get.

• •

  These checks will start (3) and end when all of the extra money is paid to you.

   

If You Disagree With The Decision

3180A - Domestic

3180B - Foreign

 

If You Want Help With Your Appeal¹

3100E

 

If You Have Any Questions

3901C - Domestic

3901D - Foreign

 

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

Send when the conserved amount returned by the former payee is paid to the beneficiary in monthly installments.

 

Fill-ins:

1. (1) 

   amount returned by the former payee

2. (2) 

   amount of each monthly installment

3. (3) 

   month, day, year the first installment will be paid in the format, August 10, 1992

See NL 00703.180 for 3180A and 3180B text. See NL 00703.100 for 3100E text.

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