We are writing to tell you that we plan to reduce (1) Social Security benefits as a (2) . This is because we learned that (3) a government pension. Based on the information we have, we should have reduced (4) Social Security benefits starting (5) .

 

The Information We Have

When we matched our computer records with the Office of Personnel Management’s records. We learned the following about (6) pension.

 

Please read the enclosed fact sheet, “Government Pension Offset.” This fact sheet will give you more information about how (9) benefits may change.

 

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 from the date of this letter, we will assume the information in this letter is correct and use it to reduce (10) Social Security benefits.

We will send another letter at that time. It will explain the change in (11) benefits, the amount of any overpayment, and 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. 05-10007

The PC will send this notice to a beneficiary in current pay status whose benefit amount is affected because of an increase in government pension.

 

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

 

Fill-ins:

1. (1) 

   your/full name of auxiliary beneficiary, possessive

2. (2) 

   spouse/divorced spouse/widow/surviving divorced spouse/widower

3. (3) 

   you receive/he receives/she receives

4. (4) 

   your/his/her

5. (5) 

   month and year that pension began or changed

6. (6) 

   your/auxiliary beneficiary's title and surname, possessive

7. (7) 

   amount(s) of pension

8. (8) 

   effective month(s) and year(s) of pension

9. (9) 

   your/his/her

10. (10) 

    your/auxiliary beneficiary's title and surname, possessive

11. (11) 

    your/his/her

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