SSN:

We are writing to let you know that beginning (1) we will take less out of (2) Social Security payments to satisfy court order number (3) for child support, alimony, or court ordered victim restitution.

What We Will Take Out

You have given us proof that (4) a spouse and/or dependent child(ren) other than those named in the original court order. Therefore, we will take out (5) from each monthly payment.

You will receive monthly benefit payments of $ (6) beginning around (7) .

If You Have Any Questions

3901C

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  This notice is sent when we reduce the withholding percentage because the beneficiary presents proof that he/she is supporting a second family not named in the original order.

• •

  Refer to NL 00703.005E. for 3901C text.

   

Fill-ins:

1. (1) 

   month/year (MM/YYYY) change is effective

2. (2) 

   beneficiary's full name, possessive in format: Robert L. Smith's/ “your”

3. (3) 

   case/civil action number

4. (4) 

   “you are supporting”/beneficiary's last name, “is supporting” in format: Mr. Smith is supporting.

5. (5) 

   money amount or percentage of withholding

6. (6) 

   adjusted monthly benefit amount

7. (7) 

   month/day/year (MM/DD/YYYY) new payment will arrive