We are writing to tell you that we plan to (1) (2) Social Security benefits because we learned that (3) (4) (5) payments. We received this information (6) . Based on the information we have, we should have (7) the Social Security benefits beginning (8) .

 

What You Can Do

(9)

If you know that our information is wrong, please let us know right away. We cannot use this information to change Social Security benefits until we give you time to check it. You will also need to give us any proof you have that shows that our information is wrong.

 

If We Do Not Hear From You

If we do not hear from you within (10) days from the date of this letter, we will assume the information in this letter is correct and use it to (11) (12) benefits.

We will send another letter at this time. It will explain the change in (13) benefits, the amount of any overpayment, and how to appeal our decision.

• •

  You will have 60 days to ask for an appeal.

• •

  The 60 days will start the day after you receive the next letter.

   

If You Have Any Questions

3901C

 

Fill-ins:

1. (1) 

   reduce/withhold

2. (2) 

   your/full name of auxiliary beneficiary, possessive/child's first name, possessive (if only one child beneficiary)/the children's

3. (3) 

   full name of disabled worker

4. (4) 

   receives/received an increase in

5. (5) 

   workers' compensation/public disability/black lung/federal employees compensation

6. (6) 

   If computer match, fill-in:

   “when we matched computer records with the (name of the source of the computer matching information, in format; “Office of Personnel Management”) ”
   If other third party report, fill-in:
   “from (name of entity furnishing data)”

7. (7) 

   reduced/withheld

8. (8) 

   month and year offset should have begun or changed

9. (9) 

   If computer match, add:

   “We asked (full name of number holder) to check the information we received.”

10. (10) 

    30 (if computer match)/10 (if other third party report)

11. (11) 

    (Same as 1.)

12. (12) 

    your/auxiliary beneficiary title and surname, possessive/child's first name, possessive (if only one child beneficiary)/the children's

13. (13) 

    your/his/her/their