We are writing to you about the (1) benefits we sent to (2) on (3) behalf. We looked at how this payee used the benefits and found (4) used the money for (5).

How We Reached Our Determination

(6)

Information About Replacement of Benefits

A representative payee must use any benefits we pay for (7). If the payee misuses the money, we will ask them to pay it back. This only applies to cases where a payee misuses the benefits.

Since this payee used the benefits for (8), (9) not qualify for replacement of benefits.

If You Disagree With Our Determination

Please contact us within 30 days of the date you received this letter if you disagree with our determination that (10) payee used the benefits for (11). We assume you got this letter 5 days after the date on it. Please present any new facts and the reason you think our determination is wrong. We will close the case in 35 days if we do not receive a request for review from you. We will treat any new facts received after 35 days as a new case.

If You Have Any Questions

CTDO-Domestic

3901D - Foreign

The FO will send this notice to the beneficiary and/or the new representative payee when misuse is not found.

Fill-ins:

1. (1) 

   Social Security/Supplemental Security Income/Social Security and Supplemental Security Income

2. (2) 

   (payee name)

3. (3) 

   your/(beneficiary name, possessive)

4. (4) 

   they

5. (5) 

   you/(beneficiary full name)

6. (6) 

   narrative explanation of the misuse determination

7. (7) 

   you/(beneficiary full name)

8. (8) 

   you/(beneficiary full name)

9. (9) 

   you do/they do

10. (10) 

    your/(beneficiary name, possessive)

11. (11) 

    you/(beneficiary full name)