We have decided that it would be best for (1) to have (2) as (3) representative payee. This payee will get (4) payments for (5) each month and will use this money for (6) needs.

Check Information

If You Have Any Questions

3901C - Domestic

3901D - Foreign

• •

  In title II cases, the PC sends the notice to the beneficiary's legal guardian, parent or person standing in place of parent, whether or not they are former payees; or if they are unsuccessful payee applicants. Also send to an unsuccessful attorney applicant. For title XVI cases the FO should refer to GN 00503.130 on when the notice is system generated.

• •

  Select paragraph 3824B when the first payment to the new payee is different from the regular ongoing monthly benefit (retroactive benefits are due, a cost-of-living increase will occur the month after the payee change). Otherwise, select paragraph 3824A.

• •

  Select paragraph 3821A (If You Have Saved Any Money and How To Pay Us Back) if a refund of conserved funds is required.

• •

  Select paragraph 3100FC as the second paragraph in the section, “How To Pay Us Back” if refund of conserved funds is requested and the address is a foreign one. See NL 00703.100 for text.

ALERT: Since no advance notice is sent to beneficiaries living in foreign countries, the final notice must include appeal rights.

• •

  Select paragraph 3821B if a final accounting is requested.

• •

  Select 3824C in title II cases when a copy of the Award Notice is being sent to the parent, person standing in place of parent, or legal guardian.

• •

  See NL 00703.005E. for 3901C and 3901D text and fill-in.

Fill-ins:

1. (1) 

   Full name of beneficiary

2. (2) 

   name of payee

3. (3) 

   his, her

4. (4) 

   Social Security, Supplemental Security Income, Social Security and Supplemental Security Income.

5. (5) 

   First name of beneficiary, if child; if adult, “Mr.” or “Ms.” last name

6. (6) 

   his, her

7. (7) 

   If paragraph 3821A is requested:
   
   Enclosure:
   
   Return envelope

   If paragraph 3821B is requested:
   
   Enclosures:
   
   Return envelope
   
   SSA-623-OCR-SM (for domestic cases) or SSA-7161-OCR-SM (for foreign cases)

3824A

1. (1) 

   We will begin, We began

2. (2) 

   first name of beneficiary, possessive, if child; if adult, “Mrs.” or “Ms.” last name, possessive

3. (3) 

   monthly payment amount

4. (4) 

   name of payee

5. (5) 

   month, day, year change is effective, in the format of January 3, 1991

3824B

1. (1) 

   sent, will send

2. (2) 

   amount of first payment

3. (3) 

   name of payee

4. (4) 

   first name of beneficiary, if child; if adult, “Mr.” or “Ms.” last name

5. (5) 

   month, day, year payment is due in the format, June 3, 1991

6. (6) 

   will begin/began

7. (7) 

   first name of beneficiary, possessive, if child; if adult, “Mr.” or “Ms.” last name, possessive

8. (8) 

   ongoing monthly benefit amount

9. (9) 

   name of payee

10. (10) 

    month, day and year regular monthly benefit check will first be received by the payee

3821A

1. (1) 

   first name of beneficiary, possessive, if child; if adult, “Mrs.” or “Ms.” last name, possessive

2. (2) 

   him, her

3. (3) 

   name of beneficiary

4. (4) 

   Show the actual claim number (Title II cases) or Social Security number (Title XVI cases), as appropriate.

3824C

1. (1) 

   first name of beneficiary, possessive, if child; if adult, “Mr.” or “Ms.” last name, possessive

In title II cases use Form SSA-L2000-C2 (Universal Notice) and follow the notice standards. Information for this notice will be on the Form SSA-573. In title XVI cases use the SSA-L8025-U2 (Supplemental Security Income Payment Decision), or SSA-L8166-U2 (Supplemental Security Income Notice) as appropriate. In concurrent SSA/SSI cases use SSA letterhead.