We are writing to let you know that we are stopping your Social Security benefits in

(1) . This is the check you would normally get in (2) . Your benefits are stopped because (3) became age 16 in (4) .

 

How We Can Pay You

We can only continue your benefits if you have a child in your care, under age 16 or disabled, who is entitled to Social Security benefits.

We are now considering (5) claim for disability benefits. After we decide if (6) is disabled, we will let you know if you can get benefits again.

 

If You Disagree With The Decision

ALS020

 

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.

This letter is sent to a mother/father beneficiary when the last child attains age 16 and a disability determination on the child is pending. Other entitled beneficiaries will continue to receive the same benefit amount. There are six fill-ins. If the foreign referral paragraph is needed, indicate 3901D on the SSA-573 along with the appropriate fill-in.

 

Fill-ins:

1. (1) 

   month/year; e.g., July 1984

2. (2) 

   month/year; e.g., August 1984

3. (3) 

   first and last name of child

4. (4) 

   month/year

5. (5) 

   first name of child - possessive

6. (6) 

   first name of child

See NL 00703.005E. for 3901C and 3901D text and fill-in. Refer to NL 00703.100 for 3100E text. Refer to NL 00703.180 for 3180A and 3180B text.

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