We are writing to tell you about a change in (1) Social Security benefits. Beginning
(2) , we have refigured your benefits (3) .

You still will not receive regular monthly checks because (4) . If we can send you money in the future, (5) new monthly payment will be $ (6) .

 

If You Disagree With The Decision

3180A - Domestic

3180B - Foreign

 

If You Want Help with Your Appeal¹

3100E

 

If You Have Any Questions

3901C - Domestic

3901D - Foreign

 

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

• •

  Send this notice to the representative payee of a beneficiary who is in conditional status or is being suspended and no payment is being made.

   

Fill-ins:

1. (1) 

   full name of beneficiary, possessive case

2. (2) 

   effective date of change, month/year

3. (3) 

   use reason A - M or use dictated language

   (a)

   to correct the previous calculation.

   (b)

   to give credit for additional earnings.

   (c)

   to increase the rate because the benefits of another person have been terminated.

   (d)

   to decrease the rate because another person is entitled to benefits.

   (e)

   to increase the rate because a period of disability has been established.

   (f)

   to give credit for months of entitlement before full retirement age (62) for which less than the full benefit was paid.

   (g)

   to give credit for months of entitlement before full retirement age for which benefits were paid based on caring for a child who was entitled to benefits.

   (h)

   to give credit for months your deceased spouse was entitled to, but not paid, full benefits between age 62 and 65.

   (i)

   to give credit for months when you were at least full retirement age and did not receive a retirement benefit because you were working.

   (j)

   because of a special provision of the law. This special provision increases benefits for people who have worked under Social Security for many years at relatively low earnings.

   (k)

   to give credit for additional earnings and also to give credit for months after 1970 when you were at least full retirement age and did not receive a retirement benefit because you were working.

   (l)

   to decrease the benefits based on your amended annual report of earnings which shows you worked in fewer months after full retirement age than you had originally reported.

   (m)

   to give credit for months your deceased spouse was at least 65 and did not receive a retirement benefit because of work.

4. (4) 

   give reason for non-payment, for example “of her earnings”

5. (5) 

   his, her

6. (6) 

   current monthly payment amount

Refer to NL 00703.005E. for 3901C and 3901D text and fill-ins. Refer to NL 00703.180 for 3180A and 3180B text. Refer to NL 00703.100 for 3100E text.

Use Form SSA-2000-C2 (Universal Notice) and follow new notice standards. Information for this letter will be shown on SSA-573.