TN 1 (10-02)
Exhibit 1 – Due Process Notice- CDR Cessation for Whereabouts Unknown
We are writing to you about your Social Security disability payments. We've been carefully
reviewing the facts in your case. You now have a chance to give us more information
about your case.
If you disagree with our plans explained below, you should contact us within 10 days
and ask us to look at your case again. If you have any new information or concerns,
you may call, write, or visit the Social Security office nearest you. The telephone
number and address are shown at the (1) of this letter.
What We Plan To Do
Based on the facts in your file, we plan to stop your disability payments in
(2) . This is because (3) . Before we do this, we're giving you a chance to give us more information about your
case. We will look at any new information you give us before we decide whether to
stop your payments.
What You Should Do
Let us know right away if you have more information about (4) .
If You Have Any Questions
(5)
Fill-ins:
-
(1)
a. end (If sent from PC/DDS)
b. top (If sent from FO)
-
(2)
month/year of suspension, in format: July 1999
-
(3)
a. our records show that you are working
b. we cannot locate you at the last address that we have
c. we have not received the information we requested from you
d. we received information that your health has improved and you are able to work
-
(4)
a. your work and earnings
b. your current address
c. your health
d. [Dictated language for other information we requested from the beneficiary (e.g.,
the reason you did not complete the form, the reason you did not furnish the information
we requested).]
-
(5)
a. Use option a. if sent from PC/DDS
If you have any questions, you may call us toll-free at 1-800-772-1213, or call your
local Social Security office at (fill-in from DOORS). We can answer most questions
over the phone. You can also write or visit any Social Security office. The office
that serves your area is located at:
Street Address
City, State, ZIP
If you do call or visit an office, please have this letter with you. It will help
us answer your questions. Also, if you plan to visit an office, you may call ahead
to make an appointment. This will help us serve you more quickly.
b. Use option b. if sent from FO.
If you have any questions, you should call, write or visit any Social Security office.
If you call or visit our office, please have this letter with you and ask for (name
of claims representative). The telephone number is shown above.
Exhibit 2 – DIB Withdrawn Before Adjudication – Freeze Previously Allowed
We have approved your request to withdraw (1) application for disability insurance benefits on (2) .
Other Social Security Benefits
Our approval of the withdrawal affects only this application. It does not affect the
disability freeze we previously established for (3) .
You Can Cancel Your Withdrawal
If you change your mind and want to receive these benefits, you may cancel your withdrawal
by filing a written request with us. You have 60 days from the date you receive this
letter to ask for cancellation. After the 60 days are over, you will have to file
a new application if you want to receive these benefits. You will not lose any benefits
if you cancel your withdrawal within the 60 days.
If You Have Any Questions
(4)
Fill-ins:
-
(1)
a. your
b. beneficiary's full name, possessive
-
(2)
a. your record
b. the record of (number holder's full name)
-
(3)
a. you
b. beneficiary's full name
-
(4)
a. Use option a. if sent from PC/DDS
If you have any questions, you may call us toll-free at 1-800-772-1213, or call your
local Social Security office at (fill-in from DOORS). We can answer most questions
over the phone. You can also write or visit any Social Security office. The office
that serves your area is located at:
Street Address
City, State, ZIP
If you do call or visit an office, please have this letter with you. It will help
us answer your questions. Also, if you plan to visit an office, you may call ahead
to make an appointment. This will help us serve you more quickly.
b. Use option b. if sent from FO.
If you have any questions, you should call, write or visit any Social Security office.
If you call or visit our office, please have this letter with you and ask for (name
of claims representative). The telephone number is shown above.