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In title II cases, the FO is responsible for designating the notice. The PC is responsible
for all fill-ins. In title XVI the FO is responsible for the entire notice.
For change of payee situations: Send this letter when the unsuccessful applicant is
not the parent, person standing in place of the parent or legal guardian.
Fill-ins:
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(3)
Social Security, Supplemental Security Income
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(4)
If paragraph 3821A is requested:
Enclosure:
Return envelope
If paragraph 3821B is requested:
Enclosures:
Return envelope
SSA-623-OCR-SM (for domestic cases) or SSA-7161-OCR-SM (for foreign cases)
Use paragraph 3821A (“If You Have Saved Any Money” and “How To Pay Us Back” ) only if return of conserved funds is requested, i.e., to all former payees. Omit
this paragraph when this letter is sent to an unsuccessful payee applicant.
3821A
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(1)
first name of beneficiary, possessive, in the format of John's, if child; if adult,
“Mr.” or “Ms.” last name possessive in format Mr. Smith's
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(4)
actual claim number (Title II cases) or Social Security number (Title XVI), as appropriate.
Add paragraph 3100FC as the second paragraph under the caption, “How To Pay Us Back,” if a foreign address is involved. See NL 00703.100 for text.
Use paragraph 3821B if a final accounting is requested.
See NL 00703.005E. for 3901C and 3901D text and fill-in.