Please read the enclosed copy of our letter to (1) former representative payee. This is the (2) who used to manage the (3) benefits for (4) .

We have asked the former payee to return the money that was not used properly. We have determined that (5) former representative payee misused $(6) of (7) benefits. When we receive the money, we will send it to (8).

If the former payee does not pay back the money, we will replace the benefits to (9). If it is later determined that (10) did not misuse the benefits, you will be instructed to refund the money back to the Social Security Administration.

If You Have Any Questions

If you have any questions, you may call us toll-free at 1-800-772-1213 or call your local Social Security Office at (11). 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:

(12)

 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 when you arrive at the office.

Enclosure:

Copy of letter sent to former payee

Send a copy of the “Request for Repayment of Misused Funds – Advanced Notification”, NL 00703.212 notice to the new payee or beneficiary, using this notice as a cover letter. DO NOT SEND THE LIST OF AFFECTED BENEFICIARIES

For additional guidelines on sending the NL 00703.211, see GN 00604.045B.4.c.

Fill-ins:

1. (1) 

   Your/beneficiary's full name, possessive

2. (2) 

   Person/organization

3. (3) 

   Social Security, Supplemental Security Income, Social Security and Supplemental Security Income, Special Veterans’ Benefits

4. (4) 

   You/beneficiary’s full name

5. (5) 

   Your/beneficiary's full name, possessive

6. (6) 

   The amount of misused benefits

7. (7) 

   Your/beneficiary's full name, possessive

8. (8) 

   You/beneficiary’s full name

9. (9) 

   You/beneficiary’s full name

10. (10) 

    Name of misuser (former payee)

11. (11) 

    Phone number of local Social Security office

12. (12) 

    Address of local Social Security office