You asked us to hold back $ (1) from your checks each month because of your work. We will hold back this amount from your checks for (2) through (3) .

What We Will Pay And When

• •

  You will receive $ (4) around (5) . This includes a (6) of $ (7) for medicare premiums you (8) .

• •

  After that, you will receive $ (9) each month. This is the amount you asked to receive each month, less your monthly medicare premium of $ (10) .

   

Your Responsibilities

If you expect to earn more or less than $ (11) this year, please let us know right away. Any change in the amount of money you earn may change your payments.

At the end of the year, we will send you a form called the “Annual Report of Earnings.” You will need it to report how much you actually earn for the year. After you report, we will make any necessary changes to your benefits because of the earnings.

If You Have Any Questions

3901C - Domestic

• •

  After the reviewing office has approved the beneficiary's request to have his/her work suspensions prorated or deferred and the action has been processed through MADCAP, send this exhibit when SMI is involved.

   

  Fill-ins

  1. (1) 

     amount of benefits withheld

  2. (2) 

     month/year withholding begins, e.g. January 1992

  3. (3) 

     month/year withholding ends, e.g. May 1992

  4. (4) 

     amount of next check

  5. (5) 

     date of check, e.g. June 3, 1992

  6. (6) 

     refund, deduction

  7. (7) 

     amount of premiums withheld or repaid

  8. (8) 

     have already paid, owe

  9. (9) 

     amount of continuing monthly payment

  10. (10) 

      amount of SMI premium

  11. (11) 

      amount of current earnings estimate

• •

  Refer to NL 00703.005E. for 3901C text and fill-ins.

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