General Notice (Replaces SSA-3926-EP)
SOCIAL SECURITY ADMINISTRATION
Retirement, Survivors and Disability Insurance
Important Information
PSC's Name |
Street Address |
City, State, ZIP |
Date: |
Claim Number: |
Beneficiary's Name
Street Address
City, State, Zip
As we told you in our prior letter, we reviewed your case and found that you do not
have to pay us back all the money. Based on this, you will receive benefits as follows:
Month(s) |
Amount you will receive |
Amount withheld
|
Balance you owe |
11/96
|
$611.00
|
$0.00
|
$2,620.00
|
If you pay Medicare premiums, they will be deducted from the amount shown under the
heading “Amount you will receive.”
What We Will Pay and When
You will receive $611.00 for November 1996 in December 1996. After that, you will
receive $611.00 on or about the third of each month.
If You Have Any Questions
If you have any questions, you may call us toll free at 1-800-772-1213, or call your
local office at 716-343-2501. We can answer most questions over the phone. You can
also write or visit any Social Security office. The office that serves your area is
located at:
FO Street Address
City, State ZIP
If you do call or visit an office, please have this letter with you. It will help
us answer your questions. Also, if you plan to visit an office, you may call ahead
to make an appointment. This will help us serve you more quickly when you arrive at
the office.
ARC's SignatureAssistant
Regional Commissioner
Processing Center Operations
Enclosure:
Payment Stub
Refund Envelope