Social Security Administration
Retirement, Survivors, and Disability Insurance
Notice of Award
Date:
Claim
Number: XXX-XXX-XXXXA
JOHN G. BENEFICIARY
101 MAIN STREET
ANYTOWN, ST 00001
You are entitled to receive monthly retirement benefits beginning 01/2005.
What We Will Pay And When
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Your monthly benefit is $1150.00 beginning 01/2005.
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We cannot pay you now because you have an outstanding arrest warrant for a felony
crime.
You have told us that there is a good cause for not satisfying the outstanding warrant
but we need information from you to prove this. Once you submit the information necessary for us to decide if you have shown good
cause for not satisfying the outstanding warrant, we will send you another letter
to let you know if we can start paying you social security benefits.
Information About Your Benefits
Beginning January 2005, the law prohibits us from paying Social Security benefits
to individuals who have an outstanding arrest warrant for a felony crime (or, in jurisdictions
that do not define crimes as felonies, a crime that is punishable by death or imprisonment
for a term exceeding 1 year), or who have violated a condition of probation or parole
under Federal or State law. We have information that you fall into one of these categories.
The Information We Have
Our records show that the XYZ Sheriffs Dept., 123 Cypress Lane, New York, NY 12345,
PHONE: 800-923-4567, issued a warrant for your arrest for a violent crime on 1/5/2005.
The warrant information we have is:
Warrant number: NY123456
Originating case number: 2345678
National Crime Information Center number: 3456789
Social Security cannot provide further information about the warrant. Please contact
the XYZ Sheriffs Dept. directly.
How Your Benefits Can Be Paid
We will pay you if you contact us at any time and can show us that any of the following
apply:
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The warrant was issued incorrectly in your name because someone stole your identity.
To prove this, submit a copy of the police report that you filed as a victim of identity
theft or another official document from the court or the warrant issuing agency stating
that the warrant was erroneously issued in your name.
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You were found not guilty of the criminal offense. To prove this, submit a copy of
the court docket indicating you were found not guilty of the criminal charges or a
copy of the court decision showing that you were found not guilty of the criminal
charges.
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The underlying charges relating to the criminal offense were dismissed. To prove this,
submit a copy of the court docket indicating charges were dismissed or another official
court or law enforcement agency document stating that it dismissed the criminal charges.
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The warrant for your arrest for the criminal offense was withdrawn. To prove this,
submit a copy of the court docket or another official document from the issuing agency,
indicating the warrant in question was withdrawn.
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You were otherwise cleared of the criminal offense. To prove this, submit a copy of
the court docket or other court document indicating you were cleared of the criminal
charges.
If none of the above applies, we also may pay you benefits if you contact us within
12 months from the date of this letter and can show us that:
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The crime for which the warrant was issued or the probation or parole violation was
both nonviolent and not drug related and, if a probation or parole violation is involved,
the original crime(s) for which you were paroled or put on probation was both nonviolent
and not drug related.
And
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You have neither been convicted of nor pled guilty to another felony crime since the
date of the warrant.
And
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The law enforcement agency that issued the warrant reports that it will not extradite
you for the charges on the warrant or that it will not take action on the warrant
for your arrest.
Or
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The crime for which the warrant was issued is based on or the probation or parole
violation was both nonviolent and not drug related and, if a probation or parole violation
is involved, the original crime(s) for which you were paroled or put on probation
was both nonviolent and not drug related.
And
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You have neither been convicted of nor pled guilty to another felony crime since the
date of the warrant.
And
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The only existing warrant was issued 10 or more years ago.
And
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Your medical condition impairs your mental capability to resolve the warrant; or you
are incapable of managing your benefits; or you are legally incompetent; or Social
Security has appointed a representative payee to handle your benefits or you are residing
in a long-term care facility, such as a nursing home or mental treatment/care facility.
Other Social Security Benefits
The benefits described in this letter are the only one you can receive from Social
Security. If you think you might qualify for another kind of Social Security benefit
in the future, you will have to file another application.
If You Disagree With The Decision
If you disagree with this decision, you have the right to appeal. We will review your
case and consider any new facts you have. A person who did not make the first decision
will decide your case. We will correct any mistakes. We will review those parts of
the decision which you believe are wrong and will look at any new facts you have.
We may also review those parts which you believe are correct and may make them unfavorable
or less favorable to you.
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You have 60 days to ask for an appeal.
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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.
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You must have a good reason for waiting more than 60 days to ask for an appeal.
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You have to ask for an appeal in writing. We will ask you to sign a Form SSA-561-U2,
called "Request for Reconsideration." Contact one of our offices if you want help.
Please read the enclosed pamphlet, "Your Right to Question the Decision Made on Your
Social Security Claim." It contains more information about the appeal.
If You Want Help With Your Appeal
You can have a friend, representative, or someone else help you. There are groups
that can help you find a representative or give you free legal services if you qualify.
There are also representatives who do not charge unless you win your appeal. Your
Social Security office has a list of groups that can help you with your appeal. If
you get someone to help you, you should let us know. If you hire someone, we must
approve the fee before they can collect it.
Enclosure(s):
Pub 05-10077
NOTE: This notice requires the general close-out and referral paragraphs and the appropriate
signature for the notice. See NL 00601.040 for additional paragraphs required on post-entitlement notices; e.g., overpayment
or underpayment paragraphs, etc. See NL 00601.003 for name and signature requirements on notices.