We have decided that it is best for (1) to have (2) (3) checks paid directly to (4) .

Check Information

If You Disagree With the Decision

If you disagree with the decision, you have the right to appeal. We will review your case again and consider any new facts you have. (5) 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.

(Optional)

If You Want Help With Your Appeal

3215E

If You Have Any Questions

3901C - Domestic

3901D - Foreign

Enclosure:

Pamphlet No. SSA-05-10058

¹ Delete this sentence for foreign claims.

• •

  In title II cases, the FO is responsible for designating this notice. When a copy of the award notice will be sent to the parent or legal guardian, the FO will designate optional paragraph 3828A to be included in the notice. The PC is responsible for providing all necessary fill-ins. In title XVI cases, the FO is responsible for the entire notice.

• •

  Select paragraph 3828B when the first payment to the beneficiary is different than 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 3828A.

• •

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

• •

  Use Optional paragraph 3828C in title II cases whenever we are sending a copy of the Notice of Award to the beneficiary.

Fill-ins:

1. (1) 

   name of beneficiary

2. (2) 

   his, her

3. (3) 

   Social Security, Supplemental Security Income.

4. (4) 

   him, her

5. (5) 

   Include this sentence only in title II cases.

3828A

1. (1) 

   We will begin, we began

2. (2) 

   first name of beneficiary, possessive case

3. (3) 

   monthly payment amount

4. (4) 

   him, her

5. (5) 

   month, day year change is effective, in the format of January 3, 1992.

3828B

1. (1) 

   sent, will send

2. (2) 

   amount of first payment

3. (3) 

   first name of beneficiary

4. (4) 

   month, day, year payment is due in the format of June 3, 1992

5. (5) 

   will begin/began

6. (6) 

   his, her

7. (7) 

   ongoing monthly benefit amount

8. (8) 

   him, her

9. (9) 

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

3828C

1. (1) 

   first name of minor child or incompetent beneficiary.

3828D

1. (1) 

   first name of minor child or incompetent beneficiary, possessive case

2. (2) 

   his, her

3. (3) 

   his, her

4. (4) 

   his, her

5. (5) 

   his, her

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

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 Form SSA-L8025-U2 (Supplemental Security Income Payment Decision) or SSA-L8166-U2 (Supplemental Security Income Notice) as appropriate. Refer to NL 00801.015C.