Paragraph #1 – Withdrawal prior to determination of SVB entitlement
We have approved __(1)__ request for withdrawal of __(2)__ application for SVB payments.
Therefore, we have not determined whether or not __(3)__ entitled to receive SVB payments.
Paragraph #1 Fill-ins:
(1) (your) or (veteran's name, possessive)
(2) (your), (his) or (her)
(3) (you are) or (veteran's name is)
Paragraph #2 – Withdrawal after determination of SVB entitlement; no SVB payments made
We have approved __(1)__ request for withdrawal of __(2)__ application for SVB payments.
SVB payments will not be sent to __(3)__.
Paragraph #2 Fill-ins:
(1) (your) or (veteran's name, possessive)
(2) (your), (his) or (her)
(3) (you) or (veteran's name)
Paragraph #3 – Right to Cancel SVB Withdrawal Request
If __(1)___ to pursue the SVB claim, __(2)__ should tell us no later than 60 days
after the date of this notice. If __(3)__ mind after that, please contact us immediately.
You will have to file a new application and show that __(4)___ all of the requirements
for entitlement to SVB payments based on the new application.
Paragraph #3 Fill-ins:
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(1)
(you change your mind and decide you want),
(he changes his mind and decides he wants),
(she changes her mind and decides she wants)
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-
(3)
(you change your), (he changes his), (she changes her)
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(4)
(you meet) or (veteran's name meets)
Paragraph #4 - Withdrawal requested after SVB payment(s) made — refund requested
___(1)___ asked us to withdraw ___(2)___ application for SVB payments. We cannot do
this until ___(3)___ back the ___(4)___ we have already sent to ___(5)___. ___(6)___
must also return to the address shown at the top of this letter any SVB payments ___(7)___
from now on. As soon as ___(8)___ this money, ___(9)___ application will be withdrawn.
If ___(10)___ done so already, please mail a check or money order in the enclosed
envelope to the above address. Make it payable to the Social Security Administration,
___(11)___. Do not mail cash to the Social Security office.
Enclosure:
Refund Envelope
Paragraph #4 Fill-ins
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(1)
(You have) or (Mr. or Ms. (veteran's name) has)
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-
(3)
(you pay), (he pays) or (she pays)
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-
-
-
(7)
(you get), (he gets) or (she gets)
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(8)
(you repay), (he repays) or (she repays)
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-
(10)
(you have not), (he has not) or (she has not)
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(11)
(Recipient's Social Security number)
Paragraph #5 – Refund is required and the address is foreign
Please send your check or money order in United States currency or in local currency
equal to the United States dollars. When you pay us in local currency, we use the
exchange rate in effect at the time we get your payment. If this causes a difference
between the amount you pay us and the amount you owe us, we will let you know. If
you cannot mail your payment directly to us, please go to one of the offices shown
in the last section "If You Have Questions or Need Help" for help in making the refund.
Paragraph # 6 - Recipient requested withdrawal—SVB refunded
You asked that ___(1)___ application for Special Veterans Benefits be withdrawn. Since
you paid back the money we sent ___(2)___ we have approved ___(3)___ request. No more
SVB payments will be sent to ___(4)___.
Paragraph #6 Fill-ins:
-
(1)
(your) or (veteran's name, possessive)
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(2)
(you) or (on his behalf) or (on her behalf)
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-
Paragraph # 7 - Recipient requests timely cancellation of withdrawal (within the 60-day period)—request
approved
Because you changed your mind and do not want to withdraw ___(1)___ application for
Special Veterans Benefits, _____(2)_____ ___(3)____ __(4)__ .
Paragraph #7 Fill-ins:
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(1)
(your) or (veteran's name, possessive)
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(2)
(we will being sending your payments right away. You will also receive any payments
you returned); or
(we will begin sending his payments right away. You will also receive any payments
that were returned); or
(we will begin sending her payments right away. You will also receive any payments
that were returned); or
(we can pay you); or
(we can pay him); or
(we can pay her); or
(we have reviewed your claim. Based on the information available to us, we find that
you are not entitled to payment at this time.); or
(we have reviewed his claim. Based on the information available to us, we find that
he is not entitled to payment at this time.); or
(we have reviewed her claim. Based on the information available to us, we find that
she is not entitled to payment at this time.)
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(3)
for (month/year)) or (for (month/year) through (month/year) or (for (month/year on)
or (NULL)
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(4)
(,) or (and) or (.) or (NULL)
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(5)
(We will send you another letter giving you more information about your claim) or
(we will send you another letter giving you more information about his claim) or (we
will send you another letter giving you more information about her claim) or (NULL)
Paragraph # 8 – Recipient requests timely cancellation of withdrawal — SVB qualification notice
previously sent — Individual has not established foreign residency
Because you changed your mind and do not want to withdraw ___(1)___ application for
Special Veterans Benefits, the information in our letter of ___(2)___ still applies.
___(3)___ must reside outside the United States to be entitled to receive SVB payments.
If ___(4)___ not begin residing outside the United States by ___(5)___, we will deny
your claim.
Paragraph #8 Fill-ins:
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(1)
(your), (veteran's name, possessive)
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(2)
(date of qualification notice)
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(3)
(you) or (veteran's name)
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(4)
(you do) or (he does) or (she does)
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(5)
(month/day/year)—the latter of the last day of the fourth full month after the date
of the qualification notice; or, the last day of the calendar month after the date
of this notice).
Appeal Paragraph – (To be included when specified in VB 00201.100)
If You Disagree With The Decision
If you disagree with our decision, you have the right to appeal. A person who did
not make the first decision will decide your case. We will review those parts of the
decision with which you disagree and will look at any new facts you have.
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•
You have 60 days to ask for an appeal.
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•
You must put the request for an appeal in writing.
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•
The 60 days start the day after you receive this letter.
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•
You must have a good reason if you wait more than 60 days to ask for an appeal.
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•
You may make your request through any U.S. Social Security office, United States Embassy
or consulate, or the U.S. Veterans Affairs Regional Office in Manila. Or, you may
write to us at the address shown at the top of this letter.
Please read the enclosed leaflet, "Your Right to Question the Decision Made on Your
Social Security Claim." It contains more information about an appeal.
Enclosure: Pub. 05-10058