• •

  Use this notice for miscellaneous adjustments in payment; e.g., reinstatement due to the attainment of full retirement age, cessation of foreign employment, “in-his-/her-care” situations, cases in which the benefit payments were suspended pending the receipt of a correct address or a determination of a representative payee, etc. It may also be used as the notice of reinstatement of benefit payments to an auxiliary beneficiary whose benefits are not combined with those of the insured individual.

• •

  Always include the appropriate standard or dictated paragraph explaining the reason the payment is being resumed to this notice.

We are writing to tell you about a change in your Social Security checks. The rest of this letter will tell you why we are changing your checks, what we will pay you, and when your checks will (1).

Why We Are Changing Your Checks

(2)

What We Will Pay and When

• •

  You will receive $ (3) around (4) . This is the money you are due for (5) . (6) .

• •

  After that, you will receive $ (7) each month. (8) .

If You Disagree With the Decision (ALSC04)

If you do not agree with this decision, you have the right to appeal. We will review your case and look at any new facts you have. A person who did not make the first decision will decide your case. We will review the parts of the decision that you think are wrong and correct any mistakes. We may also review the parts of our decision that you think are right. We will make a decision that may or may not be in your favor.

• •

  You have 60 days to ask for an appeal in writing.

• •

  The 60 days start the day after you receive this letter. We assume you got this letter 5 days after the date on it unless you show us that you did not get it within the 5-day period.

• •

  You must have a good reason if you wait more than 60 days to ask for an appeal.

You can file an appeal with any Social Security office. You must ask for an appeal in writing. Please use our "Request for Reconsideration" form, SSA-561. You may go to our website at *F1 to find the form SSA-561. You can also contact us by phone, mail, or come into an office to request the form. If you need help to fill out the form, we can help you by phone or in person. (ALS020)

If You Want Help With Your Appeal¹ (REPC01)

You can have a friend, representative, or someone else help you. There are groups that can help you find a representative or give you free legal services if you qualify. There also are representatives who do not charge unless you win your appeal. Your local Social Security office has a list of groups that can help you with your appeal.

If you get someone to help you, you should let us know. If you hire someone, we must approve the fee before he or she can collect it. And if you hire a representative who is eligible for direct pay, we will withhold up to 25 percent of any past due benefits to pay toward the fee. (REP001)

Your Responsibilities

If the information you have given us changes, it could affect your benefits. For this reason, it is important that you report changes to us right away.

If You Have Any Questions

CTDO - Domestic

3901D – Foreign

¹ If the person lives outside the U.S. or has an attorney, omit this paragraph.

1. 1. 

   change, or start

2. 2. 

   Add standard or dictated paragraph to explain why payment is being resumed/changed

3. 3. 

   amount of next payment

4. 4. 

   month/day/year when payment should be received (in format of February 8, 1992)

5. 5. 

   months for which payment is due. First month is first month payment is due. Last month is last month used to figure PMA. Format is “January through October” unless period spans 2 calendar years. If so, format is “January 1992 through October 1993.”

6. 6. 

   If Medicare deduction applies, then:
   
   “We took out $ (6A) for Medicare premiums for (6B) .”

   (6A)

   Amount of premium deducted for Medicare

   (6B)

   month or months for which premium is deducted

7. 7. 

   ongoing MPA in format $$$¢¢

8. 8. 

   If Medicare deduction applies, then:
   
   “This amount is your regular monthly benefit, minus $(8A) for your monthly Medicare premium.”

   (8A)

   amount to be deducted for premium

   • •

     use 3311A if the person lives in the U.S.

   • •

     use 3311B if the person lives outside the U.S.

   • •

     Refer to NL 00703.100 for REPC01and REP002 text, NL 00703.005E for CTDO and 3901D text and fill-ins and to NL 00703.180 for ALSC04 and ALS020 text.