Effective Dates: 04/01/2022 - Present Previous | Next

TN 85 (04-22)

NL 00703.702 Withdrawal — 30 Day Final Request

Document Identifier for Word Processor: E3702

Letterhead - Social Security Benefit Information

A. EXHIBIT LETTER

 

 
E3702.1 We have not heard from you since we told you that we would approve (1) request to withdraw (2) claim for (3). We will process the withdrawal only if: We hear from (4) in 30 days, and (5) the $ (6) (7) received. If (8) to withdraw (9) claim, (10) must send us a check or money order for $ (11). Make the check or money order payable to the Social Security Administration. Be sure to write (12) Social Security Claim Number on (13) payment. Please mail the payment to us using the enclosed refund envelope. Do not mail (14) payment to the address at the top of this notice.
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Enclosure:

Refund envelope

B. REQUESTING INSTRUCTIONS

  • •

    The request for this letter may be made on Form SSA-573 or SSA-559 by the claims authorizer. The claims authorizer will furnish all information and, if necessary, any additional paragraphs that may be needed.

     

  • •

    Fill-ins:

    1. (1) 

      your/full name(possessive)

    2. (2) 

      your/his/her

    3. (3) 

      A(retirement benefits)/B(disability benefits)/C(survivor's benefits)/D(retirement benefits and Medicare)/E(disability benefits and Medicare)/F(survivor's benefits and Medicare)/G(Medicare)

    4. (4) 

      you/him/her

    5. (5) 

      you repay/he repays/she repays

    6. (6) 

      total amount to be repaid

    7. (7) 

      you/he/she

    8. (8) 

      you still want/he still wants/she still wants

    9. (9) 

      your/his/her

    10. (10) 

      you/he/she

    11. (11) 

      total amount to be repaid

    12. (12) 

      your/his/her

    13. (13) 

      your/his/her

    14. (14) 

      your/his/her

C. TYPING INSTRUCTIONS

Use SSA-L2000-C2. The typist should enclose a self-addressed envelope with the notice and the claim number should be written on the inside of the envelope below the flap.

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900703702
NL 00703.702 - Withdrawal — 30 Day Final Request - 04/01/2022
Batch run: 04/01/2022
Rev:04/01/2022