The request for withdrawal of your claim for (1) benefits will have the effect of cancelling your previous claim, and the claims of
the other members of your family who applied on your Social Security record. You must
repay all the benefits paid to you and your family based on previous claims before
we can approve your request for withdrawal.
You, your spouse and child became entitled to benefits effective (2) . At the monthly rate established for your family, you received $ (3) , your spouse and child each received
$ (4) . The last payment you received was for (5) . Therefore, you and your family received a total of $ (6) which must be repaid.
If you wish to withdraw your claim, send a certified check or money order for $ (6)
, made payable to the Social Security Administration. Mail your payment to us using
the enclosed refund envelope. Please do not mail your payment to the address at the
top of this notice. Be sure to write the Social Security claim number listed at the
top of this notice on the check or money order.