This is to let you know that we have decided that __(1)__ not entitled to Special Veterans Benefits (SVB) under the provisions of title VIII of the Social Security Act.

Why We Can't Pay You

To receive an SVB payment __(2)__ must meet all of the requirements in the law. Our records show that __(3)__ not meet the requirements for the following reason(s).

[Denial Paragraphs]

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. We may also review those parts with which you agree and may make them unfavorable or less favorable to you.

• •

  You have 60 days to ask for an appeal.

• •

  You must put the request for an appeal in writing.

• •

  The 60 days start the day after you receive this letter.

• •

  You must have a good reason if you wait more than 60 days to ask for an appeal.

• •

  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.

Other Social Security Benefit Information

The application __(4)__ filed for SVB was also an application for Social Security benefits. We looked into this and decided __(5)__ not entitled to receive any Social Security benefits except the benefit, if any, that __(6)__ already getting. If you disagree with the decision, you have the right to appeal. The review described above is the only kind of appeal __(7)__ can have regarding Social Security benefits.

The application __(8)__ filed for SVB was also an application for Supplemental Security Income (SSI) benefits. We looked into this, and decided __(9)__ not eligible to receive SSI benefits except the benefit, if any, that __(10)__ already getting. If you disagree with this decision, you have the right to appeal. There are two ways to appeal.

• •

  You may request that the case be reviewed as explained above; or

• •

  You may request an informal conference with the person who will make a decision on the case. You can tell that person why you think you're right. You can give us more facts to help prove you're right. You can bring other people to help explain __(11)__ case.

New Application

You have the right to file a new application at any time, but filing a new application is not the same as appealing this decision. If you disagree with this decision, and you file a new application instead of appealing, __(12)__ might lose some benefits, or not qualify for any benefits. So, if you disagree with this decision, you should file an appeal within 60 days.

If You Have Questions or Need Help

[Domestic Optional Paragraph]

If you have any questions, you may call, write or visit any Social Security office. If you call or visit an office, please have this letter with you. The telephone number for our office is shown at the top of page one.

Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you better when you arrive at the office.

[Foreign Optional Paragraph]

If you have questions, you should contact one of the offices shown below. You may also write to us at the address shown at the top of this letter. However, if you call or visit an office, please have this letter with you.

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  If you live in Canada, contact any U.S. Social Security office.

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  If you live in Guam, Puerto Rico, Samoa or the U.S. Virgin Islands, you should contact the nearest U.S. Social Security office.

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  If you live in Mexico, contact any U.S. Social Security office or the nearest United States Embassy or consulate.

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  In the Philippines, please call 523-1001 extensions 2516 or 2645 from 8:00am to 2:00p.m. or write/visit SSA Division, U.S. Department of Veterans Affairs, 1131 Roxas Boulevard, 0930 Manila.

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  If you live in any other country, you should contact the nearest United States Embassy or consulate.

Notice Fill-ins:

1. (1) 

   (you are) or (veteran's name is)

2. (2) 

   (you) or (veteran's name)

3. (3) 

   (you do) or (he does, she does)

4. (4) 

   (you) or (veteran's name)

5. (5) 

   (you are) or (he is, she is)

6. (6) 

   (you are) or (he is, she is)

7. (7) 

   (you) or (he, she)

8. (8) 

   (you) or (veteran's name)

9. (9) 

   (you are) or (he is, she is)

10. (10) 

    (you are) or (he is, she)

11. (11) 

    (your) or (possessive form of veteran's name)

12. (12) 

    (you) or (veteran's name)

Denial reason Fill-ins:

1. (1) 

   (You) or (veteran's name)

2. (2) 

   (You do) or (veteran's name does)

3. (3) 

   (You were) or (veteran's name was)

4. (4) 

   (You were) or (veteran's name was)

5. (5) 

   (You have) or (veteran's name has)

6. (6) 

   (current SVB payment)

7. (7) 

   (You) or (veteran's name)

8. (8) 

   (you) or (he, she)

9. (9) 

   (You) or (veteran's name)

10. (10) 

    (you) or (he, she)

11. (11) 

    (you were) or (he was, she was)

The FO is responsible for sending this notice. However, in cases where the claim originated in an area not serviced by a FO, the CPS is responsible for sending this notice.

If the contact is in the United States, request the Domestic Optional Paragraph. If the contact is outside the United States, request the Foreign Optional Paragraph.

Enclose SSA Pub. 05-10058, “Your Right to Question the Decision Made on Your Social Security Claim.”