We are writing to tell you that we learned (1) a pension based on work not covered by Social Security. When (2) this type of pension, we must use a special formula to figure (3) monthly benefits from us. (4) benefit amount will be less than (5) would receive if (6) not getting the pension.

 

The Information We Have

We matched our computer records with the Office of Personnel Management’s records. We learned the following about (7) pension.

 

Please read the enclosed fact sheet, “Windfall Elimination Provision.” This fact sheet will give you more information about how a pension affects benefits.

 

What You Can Do

Please let us know right away if any of this information is wrong. We cannot use this information to figure Social Security benefits until we give you time to check it. You will also need to give us any proof you have that shows that our information is wrong.

 

If We Do Not Hear From You

If we do not hear from you within 30 days of the date on this letter, we will assume the information we have is correct. We will use this special formula to figure (10) benefits from us.

We will send another letter at that time. It will explain how to appeal our decision.

• •

  You will have 60 days to ask for an appeal.

• •

  The 60 days will start the day after you receive the next letter.

   

If You Have Any Questions

3901C - Domestic

3901D - Foreign

 

Enclosure:

SSA Pub. No. 05-10045

The FO will send this notice only if:

• •

  the computer match information does not agree with the NH's allegation at the time of filing and

• •

  we cannot verify this information with either the NH or the NH's employer.

   

Refer to NL 00703.005E. for 3901C and 3901D text and fill-ins.

 

Fill-ins:

1. (1) 

   you receive/[benficiary’s name] receives

2. (2) 

   you receive/he receives/she receives

3. (3) 

   Your/his/her

4. (4) 

   Your/Name

5. (5) 

   You/he/she

6. (6) 

   you were/he was/she was

7. (7) 

   your/Name

8. (8) 

   Amount of pension

9. (9) 

   Date

10. (10) 

    Your/[beneficiary’s name] receives

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