The request for withdrawal of your claim for (1) benefits will have the effect of cancelling your previous claim, and the claims of the other members of your family who applied on your Social Security record. You must repay all the benefits paid to you and your family based on previous claims before we can approve your request for withdrawal.

You, your spouse and child became entitled to benefits effective (2) . At the monthly rate established for your family, you received $ (3) , your spouse and child each received
$ (4) . The last payment you received was for (5) . Therefore, you and your family received a total of $ (6) which must be repaid.

If you wish to withdraw your claim, send a certified check or money order for $ (6) , made payable to the Social Security Administration. Mail your payment to us using the enclosed refund envelope. Please do not mail your payment to the address at the top of this notice. Be sure to write the Social Security claim number listed at the top of this notice on the check or money order.

3700B

 

Enclosure:

Refund envelope

The request for this letter may be made on Form SSA-573 or SSA-559 by the claims authorizer or by the benefit authorizer. The authorizer will furnish the fill-in information and, if necessary, any additional paragraphs that may be needed. Refer to NL 00703.700 for 3700B text.

 

Fill-ins:

1. (1) 

   Type of benefits, e.g. "'retirement” or “disability”

2. (2) 

   Month/Year monthly benefits became effective

3. (3) 

   Total benefits NH received

4. (4) 

   Total benefits auxiliaries received

5. (5) 

   Month/Year of last payment

6. (6) 

   Total benefits NH and auxiliaries received

Use Form SSA-L2000-C2. The typist should enclose a self-addressed envelope with the notice and the claim number should be written on the inside of the envelope below the flap.