TN 85 (04-22)
Document Identifier for Word Processor: E3702
Letterhead - Social Security Benefit Information
Enclosure:
Refund envelope
The request for this letter may be made on Form SSA-573 or SSA-559 by the claims authorizer. The claims authorizer will furnish all information and, if necessary, any additional paragraphs that may be needed.
Fill-ins:
your/full name(possessive)
your/his/her
A(retirement benefits)/B(disability benefits)/C(survivor's benefits)/D(retirement benefits and Medicare)/E(disability benefits and Medicare)/F(survivor's benefits and Medicare)/G(Medicare)
you/him/her
you repay/he repays/she repays
total amount to be repaid
you/he/she
you still want/he still wants/she still wants
Use 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.