Use Exhibit 1 to inform an individual of SSA's action on:

• •

  requests for withdrawal of an SVB application; and/or

• •

  requests to cancel a withdrawal requested on an SVB application.

Social Security Administration

===================================================================

Special Veterans Benefits

Address:  

Phone: FAX:

Office Hours:

Date:

Dear :

We are writing to you about your application for Special Veterans Benefits (SVB).

If You Have Questions or Need Help

Paragraph #1 – Withdrawal prior to determination of SVB entitlement

We have approved __(1)__ request for withdrawal of __(2)__ application for SVB payments. Therefore, we have not determined whether or not __(3)__ entitled to receive SVB payments.

Paragraph #1 Fill-ins:

(1) (your) or (veteran's name, possessive)

(2) (your), (his) or (her)

(3) (you are) or (veteran's name is)

Paragraph #2 – Withdrawal after determination of SVB entitlement; no SVB payments made

We have approved __(1)__ request for withdrawal of __(2)__ application for SVB payments. SVB payments will not be sent to __(3)__.

Paragraph #2 Fill-ins:

(1) (your) or (veteran's name, possessive)

(2) (your), (his) or (her)

(3) (you) or (veteran's name)

Paragraph #3 – Right to Cancel SVB Withdrawal Request

If ­­­__(1)___ to pursue the SVB claim, __(2)__ should tell us no later than 60 days after the date of this notice. If __(3)__ mind after that, please contact us immediately. You will have to file a new application and show that __(4)___ all of the requirements for entitlement to SVB payments based on the new application.

Paragraph #3 Fill-ins:

1. (1) 

   (you change your mind and decide you want),

   (he changes his mind and decides he wants),

   (she changes her mind and decides she wants)

2. (2) 

   (you), (he), or (she)

3. (3) 

   (you change your), (he changes his), (she changes her)

4. (4) 

   (you meet) or (veteran's name meets)

Paragraph #4 - Withdrawal requested after SVB payment(s) made — refund requested

___(1)___ asked us to withdraw ___(2)___ application for SVB payments. We cannot do this until ___(3)___ back the ___(4)___ we have already sent to ___(5)___. ___(6)___ must also return to the address shown at the top of this letter any SVB payments ___(7)___ from now on. As soon as ___(8)___ this money, ___(9)___ application will be withdrawn. If ___(10)___ done so already, please mail a check or money order in the enclosed envelope to the above address. Make it payable to the Social Security Administration, ___(11)___. Do not mail cash to the Social Security office.

Enclosure:

Refund Envelope

Paragraph #4 Fill-ins

1. (1) 

   (You have) or (Mr. or Ms. (veteran's name) has)

2. (2) 

   (your), (his) or (her)

3. (3) 

   (you pay), (he pays) or (she pays)

4. (4) 

   $$$.¢¢

5. (5) 

   (you), (him) or (her)

6. (6) 

   (You), (He) or (She)

7. (7) 

   (you get), (he gets) or (she gets)

8. (8) 

   (you repay), (he repays) or (she repays)

9. (9) 

   (your), (his) or (her)

10. (10) 

    (you have not), (he has not) or (she has not)

11. (11) 

    (Recipient's Social Security number)

Paragraph #5 – Refund is required and the address is foreign

Please send your check or money order in United States currency or in local currency equal to the United States dollars. When you pay us in local currency, we use the exchange rate in effect at the time we get your payment. If this causes a difference between the amount you pay us and the amount you owe us, we will let you know. If you cannot mail your payment directly to us, please go to one of the offices shown in the last section "If You Have Questions or Need Help" for help in making the refund.

Paragraph # 6 - Recipient requested withdrawal—SVB refunded

You asked that ___(1)___ application for Special Veterans Benefits be withdrawn. Since you paid back the money we sent ___(2)___ we have approved ___(3)___ request. No more SVB payments will be sent to ___(4)___.

Paragraph #6 Fill-ins:

1. (1) 

   (your) or (veteran's name, possessive)

2. (2) 

   (you) or (on his behalf) or (on her behalf)

3. (3) 

   (your) or (the)

4. (4) 

   (you) (him) (her)

Paragraph # 7 - Recipient requests timely cancellation of withdrawal (within the 60-day period)—request approved

Because you changed your mind and do not want to withdraw ___(1)___ application for Special Veterans Benefits, _____(2)_____ ___(3)____ __(4)__ .

Paragraph #7 Fill-ins:

1. (1) 

   (your) or (veteran's name, possessive)

2. (2) 

   (we will being sending your payments right away. You will also receive any payments

   you returned); or

   (we will begin sending his payments right away. You will also receive any payments that were returned); or

   (we will begin sending her payments right away. You will also receive any payments that were returned); or

   (we can pay you); or

   (we can pay him); or

   (we can pay her); or

   (we have reviewed your claim. Based on the information available to us, we find that you are not entitled to payment at this time.); or

   (we have reviewed his claim. Based on the information available to us, we find that he is not entitled to payment at this time.); or

   (we have reviewed her claim. Based on the information available to us, we find that she is not entitled to payment at this time.)

3. (3) 

   for (month/year)) or (for (month/year) through (month/year) or (for (month/year on) or      (NULL)

4. (4) 

   (,) or (and) or (.) or (NULL)

5. (5) 

   (We will send you another letter giving you more information about your claim) or (we will send you another letter giving you more information about his claim) or (we will send you another letter giving you more information about her claim) or (NULL)

Paragraph # 8 – Recipient requests timely cancellation of withdrawal — SVB qualification notice previously sent — Individual has not established foreign residency

Because you changed your mind and do not want to withdraw ___(1)___ application for Special Veterans Benefits, the information in our letter of ___(2)___ still applies. ___(3)___ must reside outside the United States to be entitled to receive SVB payments. If ___(4)___ not begin residing outside the United States by ___(5)___, we will deny your claim.

Paragraph #8 Fill-ins:

1. (1) 

   (your), (veteran's name, possessive)

2. (2) 

   (date of qualification notice)

3. (3) 

   (you) or (veteran's name)

4. (4) 

   (you do) or (he does) or (she does)

5. (5) 

   (month/day/year)—the latter of the last day of the fourth full month after the date of the qualification notice; or, the last day of the calendar month after the date of this notice).

Appeal Paragraph – (To be included when specified in VB 00201.100)

If You Disagree With The Decision

If you disagree with our decision, you have the right to appeal. A person who did not make the first decision will decide your case. We will review those parts of the decision with which you disagree and will look at any new facts you have.

• •

  You have 60 days to ask for an appeal.

• •

  You must put the request for an appeal in writing.

• •

  The 60 days start the day after you receive this letter.

• •

  You must have a good reason if you wait more than 60 days to ask for an appeal.

• •

  You may make your request through any U.S. Social Security office, United States Embassy or consulate, or the U.S. Veterans Affairs Regional Office in Manila. Or, you may write to us at the address shown at the top of this letter.

Please read the enclosed leaflet, "Your Right to Question the Decision Made on Your Social Security Claim." It contains more information about an appeal.

Enclosure: Pub. 05-10058

Insert one of the following paragraphs under the heading “If You Have Questions or Need Help” on the Exhibit 1 depending upon whether the mailing address is inside or outside of the U.S.