This is to notify you that we have decided that __(1)__ entitled to receive Special Veterans Benefits (SVB) under the provisions of Title VIII of the Social Security Act. The rest of this letter will tell you more about our decision.

When Payments Will Begin

__(2)__ entitlement to SVB begins __(3)__, because that is the first month __(4)__ a foreign resident on the first day of the month.

How Much We'll Pay

__(5)__ monthly benefit payment is $__(6)__.

The amount of __(7)__ first payment will be $__(8)__ which includes benefits due for __(9)__. Your regular monthly payment will be sent each month on or about __(10)__.

[Optional Paragraph To Explain Reduction Due To Other Benefit Income]

__(1)__ monthly SVB has been reduced to $__(2)_ from $__(3)__ because __(4)__ receiving other benefit income in the amount(s) of $__(5)__ in __(6)__ .

Payment is Based On These Facts

Payments will continue to be sent to you (or the bank you have chosen) as long as __(11)__ entitled. Our records show __(12)__ entitled because:

• •

  __(13)__ a foreign resident, and

• •

  __(14)__ not have other benefit income that is equal to or over $__(15)__, which is the maximum SVB payable at this time.

Things to Remember

_(16)_ SVB may change if _(17)_ circumstances change. Therefore, you must report any change that may affect _(18)_ SVB. You should tell us if:

• •

  __(19)__ .

• •

  the amount of __(20)__ other benefit income changes.

• •

  __(21)__ to the United States.

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. We may also review those parts with which you agree and may make them unfavorable or less favorable to you.

• •

  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.

Other Social Security Benefit Information

The application __(22)__ filed for SVB was also an application for Social Security benefits. We looked into this and decided __(23)__ not entitled to receive any Social Security benefits except the benefit, if any, that __(24)__ already getting. If you disagree with the decision, you have the right to appeal. The review described above is the only kind of appeal __(25)__ can have regarding Social Security benefits.

The application __(26)__ filed for SVB was also an application for Supplemental Security Income (SSI) benefits. We looked into this, and decided __(27)__ not eligible to receive any additional SSI benefits. If you disagree with this decision, you have the right to appeal. There are two ways to appeal.

• •

  You may request that the case be reviewed as explained above; or

• •

  You may request an informal conference with the person who will make a decision on the case. You can tell that person why you think you're right. You can give us more facts to help prove you're right. You can bring other people to help explain __(28)__ case.

If You Have Questions or Need Help

If you have questions, you should contact one of the offices shown below. You may also write to us at the address shown at the top of this.

If you call or visit an office, please have this letter with you.

• •

  If you live in Canada, contact any U.S. Social Security office.

• •

  If you live in Guam, Puerto Rico, Samoa or the U.S. Virgin Islands, you should contact the nearest U.S. Social Security office.

• •

  If you live in Mexico, contact any U.S. Social Security office or the nearest United States Embassy or consulate.

• •

  In the Philippines, please call 523-1001 extensions 2516 or 2645 from 8:00am to 2:00p.m. or write/visit SSA Division, U.S. Department of Veterans Affairs, 1131 Roxas Boulevard, 0930 Manila.

• •

  In any other country, you should contact the nearest United States Embassy or consulate.

Notice Fill-ins

1. (1) 

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

2. (2) 

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

3. (3) 

   (month/year of entitlement)

4. (4) 

   (you were) or (he was, she was)

5. (5) 

   (Your) or (possessive form of veteran's name)

6. (6) 

   (amount of monthly SVB payment)

7. (7) 

   (your) or (his, her)

8. (8) 

   (amount of first check)

9. (9) 

   (month(s)for which payment is due) If this is a current month accrual, just one month will be shown. If payment represents a prior month accrual, show months (i.e. June and July, July through September)

10. (10) 

    (month, day, year regular payment is due)

11. (11) 

    (you remain) or (veteran's name remains)

12. (12) 

    (you are) or (he is, she is)

13. (13) 

    (You are) or (he is, she is)

14. (14) 

    (You do) or (he does, she does)

15. (15) 

    (current SVB payment)

16. (16) 

    (Your) or (his, her)

17. (17) 

    (your) or (his, her)

18. (18) 

    (your) or (his, her)

19. (19) 

    (You move) or (veteran's name moves)

20. (20) 

    (your) or (his, her)

21. (21) 

    (You return) or (he returns, she returns)

22. (22) 

    (you) or (veteran's name)

23. (23) 

    (you are) or (he is, she is)

24. (24) 

    (you are) or (he is, she is)

25. (25) 

    (you) or (he, she)

26. (26) 

    (you) or (veteran's name)

27. (27) 

    (you are) or (he is, she is)

28. (28) 

    (your) or (his, her)

Other Benefit Income Reduction paragraph Fill-ins:

1. (1) 

   (Your) or (Veteran's name)

2. (2) 

   (reduced monthly payment amount)

3. (3) 

   (current maximum SVB payment)

4. (4) 

   (you are) or (he is, she is)

5. (5) 

   (amount of other benefit income)

6. (6) 

   (source of other benefit income, e.g. Social Security benefits)

The CPS is responsible for sending this notice.

If the monthly SVB benefit has been reduced by other benefit income, request the optional Other Benefit Income Reduction paragraph.

Enclose SSA Pub. 05-10058, “Your Right to Question the Decision Made on Your Social Security Claim.”