We have decided that it would be best for (1) if we continue to pay (2) (3) checks to (4) .

 

If You Disagree With The Decision

(5) , you have the right to appeal. We will review your case again and consider any new facts you have. (6) Then a person who did not make the first decision will decide your case again.

• •

  You have 60 days to ask for an appeal.

• •

  The 60 days start the day after you get this letter. We assume you got this letter 5 days after the date on it unless you show us that you did not get it within the 5-day period.¹

• •

  You will have to have a good reason for waiting more than 60 days to ask for an appeal.

• •

  To appeal, you must fill out a form called “Request for Reconsideration.” The form number is SSA-561-U2. To get this form, contact one of our offices. We can help you fill out the form.

If You Have Any Questions

3901C - Domestic

3901D - Foreign

Enclosure:

Pamphlet No. SSA-05-10058

¹ Delete this sentence for foreign cases.

In title II cases, the FO is responsible for designating the notice. The PC is responsible for all fill-ins. In title XVI cases, the FO is responsible for the entire notice.

Fill-ins:

1. (1) 

   full name of beneficiary

2. (2) 

   his, her

3. (3) 

   Social Security, Supplemental Security Income.

4. (4) 

   name of payee, unless direct payment applies. Then, use “him, or her”

5. (5) 

   If you disagree with the decision (if direct payments are being continued), If you disagree with our choice of a payee (if payments will continue to the current representative payee)

6. (6) 

   Include this sentence only in title II cases.

Select paragraph 3826D and 3215E in title XVI cases.

1. (1) 

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

2. (2) 

   his, her

3. (3) 

   his, her

4. (4) 

   his, her

5. (5) 

   his, her

6. (6) 

   his, her

7. (7) 

   his, her

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

See NL 00703.215 for 3215E text.

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 Form SSA-L8025-U2 (Supplemental Security Income Payment Decision), or Form SSA-L8166-U2 (Supplemental Security Income Notice) as appropriate. Refer to

NL 00801.015C.