We are writing to tell you that (1) no longer entitled to Social Security benefits beginning (2) because (3) entitled to a pension from the Department of Veterans Affairs (VA) in that month. We will stop the checks beginning with the check you would normally receive around (4) .

 

Why We Are Stopping Your Checks

(5) entitled to Social Security checks because of (6)   (7) military service in World War II. We cannot use this service to pay benefits if the VA uses it to pay a pension. Beginning (8) , the VA is using this military service to pay a pension, so we must stop the Social Security checks starting with that month.

 

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

This letter is sent when a widow(er)'s and child's/children's benefits are being terminated because VA payments have been awarded and insured status is no longer met.

 

Fill-ins:

1. (1) 

   beneficiary(ies) full name(s) is/are; you are

2. (2) 

   first month for which payment is not due, e.g. “June 1992”

3. (3) 

   you were, he was, she was

4. (4) 

   month/day/year of first check which will not be received

5. (5) 

   Name(s) of beneficiary(ies) was/were; you were

6. (6) 

   his, her, their, your

7. (7) 

   husband's, wife's, father's, mother's

8. (8) 

   month/year of termination

    

Optional paragraph 3364A:

1. (1) 

   COM when the action was taken, e.g. “June 1992”

2. (2) 

   month of termination through month before COM in which action taken, in format “March through June,” unless period spans 2 calendar years, in which case format is “May 1991 through June 1992”

3. (3) 

   total amount of overpayment

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 optional paragraph 3364A when an overpayment is caused by untimely processing of the termination. If this paragraph is selected, the standard overpayment paragraphs and appeals information must also be used in the notice.

Use Form SSA-L2000-C2 (Universal Notice) and follow notice standards. Information for this letter will be shown on Form SSA-573.