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

 

What We Will Pay And When

 

If you disagree with the decision

ALS020- Domestic

ALS020- Foreign

 

If you want help with your appeal¹

3100E

 

If you have any questions

3901C - Domestic

3901D - Foreign

 

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

• •

  This notice is used to inform beneficiaries when their benefit rates have been refigured. This notice will be used when the beneficiary is in current pay status or if a reinstatement action is processed in conjunction with the benefit rate adjustment when the adjustment is for one of the reasons covered in numbered paragraph 462A through M found in NL 00708.100. If none of the 462 reasons apply, or if deductions were made from the benefits payable, prepare a dictated paragraph.

If this notice is used to explain the change in rate of only one person in a combined husband/wife check, add paragraph 441 to explain that they will continue to receive their payments in a combined check.

 

Fill-ins:

1. (1) 

   your, or full name of beneficiary, possessive case

2. (2) 

   effective month/year of new monthly rate

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) 

   amount of next check

5. (5) 

   month/day/year the next check is due, e.g., “June 3, 1992”

6. (6) 

   months for which payment is due; first month is month of first increased rate. 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 May 1993.”

7. (7) 

   amount of ongoing MPA

8. (8) 

   amount of Medicare premium

Use optional third bullet 3317A in the payment section if the beneficiary is entitled to SMI.

Refer to NL 00703.005E. for 3901C and 3901D text and fill-ins. Refer to NL 00703.180 for ALS020 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 Form SSA-573.