TN 30 (03-96)
NL 00703.353 Accrued Benefits Paid in Monthly Installments to Beneficiary
Document Identifier for Word Processor: E3353
A. EXHIBIT LETTER
We are writing to tell you about extra money we are sending you.
What We Will Pay and When
You are due $(1) from (2) through (3) .
You will get this money over a period of months.
We will send you $(4) each month in addition to the regular check you already get.
These checks will start (5) and end when all of the extra money is paid to you.
If You Disagree With The Decision
3180A - Domestic
3180B - Foreign
If You Want Help With Your Appeal1
If You Have Any Questions
3901C - Domestic
3901D - Foreign
1 If the person lives outside the U.S. or has an attorney, omit this paragraph.
B. REQUESTING INSTRUCTIONS
Send when accrued benefits were withheld at the time benefits were awarded and the withheld amount will now be paid to the beneficiary in monthly installments.
total amount of money due the beneficiary
first month and year of accrued benefits were withheld in the format, May 1992
last month and year accrued benefits were withheld
Amount to be paid in each installment
month, day, year the first installment payment will be made in the format of August 3, 1992
See NL 00703.005E. for 3901C and D text and fill-in. See NL 00703.180 for 3180A and 3180B text. See NL 00703.100 for 3100E text.
C. TYPING INSTRUCTIONS
Use Form SSA-L2000-C2 (Universal Notice) and follow the notice standards. Information for this notice will be shown on Form SSA-573.