We are writing to let you know that (1) entitlement to benefits ended as of (2) . We based this on information that (3) (4) in (5) .

(If there is an overpayment, follow instructions in NL 00703.920 on what paragraphs to include.)

 

Other Social Security benefits

3922E

3922F

 

Your responsibilities

When benefits are terminated during the year, you must file an annual report if you earn over $ (6) . In this report include your earnings for the entire year both before and after your benefits were terminated.

 

If you disagree with the decision¹

ALS020

 

If you want help with your appeal²

3100E

 

If you have any questions

3901C

¹ If there is an overpayment, omit this paragraph.

² If the person has an attorney, omit this paragraph

• •

  Send when spouse, child, mother/father marries or divorces and benefits are terminated. Also, send when mother/father benefits end because the child-in-care marries.

• •

  Use paragraph 3922E when benefits to mother/father terminate because last child-in-care marries. Use paragraph 3922F when benefits to young spouse terminate because last child-in-care marries. Use Paragraph ALS020 (except when there is an overpayment), 3100E and 3901C in all cases.

• •

  Refer to NL 00703.180 for ALS020 text. Refer to NL 00703.100 for 3100E text. Refer to NL 00703.005E. for 3901C text.

   

Fill-ins:

1. (1) 

   your, full name of beneficiary, possessive format

2. (2) 

   last month/year of entitlement e.g., May 1993

3. (3) 

   you/he/she, name of beneficiary when parent's entitlement ends due to marriage of child-in-care

4. (4) 

   was married/were married/were divorced/was divorced

5. (5) 

   month/year e.g., June 1993

6. (6) 

   exempt amount for year of termination.

3925A

1. (1) 

   mother's/father's/young spouse's

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