NL 00720: Manual Adjustment, Credit and Award Process (MADCAP) Beneficiary Notice Print Program
TN 2 (09-11)
TAX002 COA — DOMESTIC TO FOREIGN (A81)
(Requested)
Caption: What We Will Pay
We will withhold Federal income tax from (1) benefit each month starting (2) . If (3) is a citizen or U.S. resident, please let us know and we will stop withholding the tax.
The United States has income tax treaties with Canada, Egypt, Germany, India, Ireland, Israel, Italy, Japan, Romania, Switzerland and the United Kingdom that may reduce or eliminate this tax on Social Security benefits for certain residents of these countries. Please contact the Internal Revenue Service to learn more about these treaties. Please contact us to stop or reduce the tax if (4) the conditions of an income tax treaty.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your
Choice 2: Beneficiary Name Possessive
Fill-in (2) - Requested As A Date CCYY
Fill-in (3) - Systems Generated
Choice 1: you become
Choice 2: he becomes
Choice 3: she becomes
Fill-in (4) - Systems Generated
Choice 1: you meet
Choice 2: he meets
Choice 3: she meets
TAX003 ALIEN WITHHOLDING TAX APPEAL (A86)
(System Generated)
Caption: Your Benefits
We use information about (1) citizenship and residency to decide whether to withhold Federal income tax from (2) benefits. If you think we have the wrong information, please contact us. We collect this tax for the Internal Revenue Service (IRS). If you have questions about this tax, or to learn about (3) appeal rights, please contact the IRS.
Fill-in values:
Fill-in (1)
Choice 1: Beneficiary Name Possessive
Choice 2: your
Fill-in (2)
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3)
Choice 1: Beneficiary Name Possessive
Choice 2: your
Fill-in (4)
Choice 1: your
Choice 2: her
Choice 3: his
TAX004 REFUND OF TAX — GENERAL PARAGRAPH FOR USE WHEN REFUND IS DUE— SSA CANNOT MAKE REFUND (A74)
(Requested)
Caption: Your Benefits
We deducted too much in Federal income tax from your Social Security benefits in (1) . Since we deducted too much, you are due a (2) refund. Because this refund is not for this year, we cannot pay you this money. IRS should refund this money.
If IRS has not refunded the (3) you are due for (4) , you must request a refund from IRS in order to get this money. To request this refund, you must file a U.S. tax return and report your income. The return should be filed with the Internal Revenue Service Center, Philadelphia, PA 19255.
IRS has advised us that there is a time limit to request a refund. Generally, you must request a refund within 3 years after the due date of the tax return for the year we deducted the tax.
Fill-in values:
Fill-in (1) - Requested As A Date In Format Shown Below
Month(s)/year(s) tax withheld
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (2) - Requested As A Money Amount In Format $$$$$.cc
Amount of refund
Fill-in (3) - Requested As A Money Amount In Format $$$$$.cc
Amount IRS can pay
Fill-in (4) - Requested As A Date In Format Shown Below
Month(s)/year(s) tax withheld
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
TAX006 ALIEN TAX DEDUCTION CONTINUES (G25)
(System Generated)
Caption: Your Benefits
We will continue to deduct Federal income tax from your monthly checks.
TAX011 COA — NONTAX TREATY TO TAX TREATY COUNTRY (A83)
(Requested)
Caption: Your Benefits
Because of the information you gave us, we are no longer deducting Federal income tax from your monthly benefits. This is because of a treaty which says we will not tax Social Security benefits paid to residents of (1) .
Please let us know if you change your address again.
Fill-in values:
Fill-in (1) Requested As A One Position Alpha Character
Choice 1: (A) Canada
Choice 2: (B) Egypt
Choice 3: (C) Germany
Choice 4: (D) India
Choice 5: (E) Ireland
Choice 6: (F) Israel
Choice 7: (G) Italy
Choice 8: (H) Japan
Choice 9: (I) Romania
Choice10: (J) the United Kingdom
TAX019 REFUND OF TAX — BENEFICIARY ESTABLISHED U.S. CITIZENSHIP OR RESIDENCY, OR RESIDENCY IN A TAX TREATY COUNTRY — SSA CANNOT MAKE REFUND (A77)
(Requested)
Caption: Your Benefits
We deducted (1) in Federal income tax from (2) Social Security benefits in (3) . Since (4) a (5) (6) , we should not have deducted any tax for this period. (7) should receive a (8) refund. Because the refund is not for this year, we cannot pay (9) this money. IRS should refund this money. If IRS has not refunded the (10) (11) due for (12) , (13) must request a refund from IRS in order to get this money. To request this refund, (14) must file a U.S. tax return and report (15) income. The return should be filed with the Internal Revenue Service Center, Philadelphia, PA 19255.
IRS has advised us that there is a time limit to request a refund. Generally, (16) must request a refund within 3 years after the due date of the tax return for the year we deducted the tax.
Fill-in values:
Fill-in (1) Requested As A Money Amount In Format $$$$$.cc
Amount of tax withheld
Fill-in (2) Systems Generated
Choice 1: your
Choice 2: Beneficiary's name possessive
Fill-in (3) Request As A Date In Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (4) Systems Generated
Choice 1: you were
Choice 2: he was
Choice 3: she was
Fill-in (5) Requested As A One Position Alpha Character
Choice 1: (A) United States citizen
Choice 2: (B) citizen of
Fill-in (6) Requested As A One Position Alpha Character
Choice 1: (A) Canada
Choice 2: (B) Egypt
Choice 3: C) Germany
Choice 4: (D) India
Choice 5: (E) Ireland
Choice 6: (F) Israel
Choice 7: (G) Italy
Choice 8: (H) Japan
Choice 9: (I) Romania
Choice 10: (J) Switzerland
Choice 11: (K) the United Kingdom
Choice 12: (L) null (if Country of Citizenship is U.S.)
Fill-in (7) Systems Generated
Choice 1: You
Choice 2: He
Choice 3: She
Fill-in (8) Requested As A Money Amount in Format $$$$$.¢¢
Amount of refund
Fill-in (9) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (10)
Amount IRS should pay
Fill-in (11) Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (12)
same as #3 above
Fill-in (13) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (14) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (15) Systems Generated
Choice 1: your
Choice 2: his
Fill-in (16) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
TAX020 REFUND OF TAX — BENEFICIARY ESTABLISHED U.S. CITIZENSHIP OR RESIDENCY, OR RESIDENCY IN A TAX TREATY COUNTRY — SSA CAN MAKE REFUND (A78)
(Requested)
Caption: Your Benefits
We deducted (1) in Federal income tax from (2) Social Security benefits in (3) . Since (4) a (5) (6) , we should not have deducted any tax for this period. (7) should receive a (8) refund. We will send (9) a check for this amount.
Fill-in values:
Fill-in (1) Requested As A Money Amount in Format $$$$$.¢¢
Amount of tax withheld
Fill-in (2) Systems Generated
Choice 1: your
Choice 2: Beneficiary's name possessive
Fill-in (3) Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (4) Systems Generated
Choice 1: you were
Choice 2: he was
Choice 3: she was
Fill-in (5) Requested As A One Position Alpha Character
Choice 1: (A) United States citizen
Choice 2: (B) citizen of
Fill-in (6) Requested As A One Position Alpha Character
Choice 1: (A) Canada
Choice 2: (B) Egypt
Choice 3: C) Germany
Choice 4: (D) India
Choice 5: (E) Ireland
Choice 6: (F) Israel
Choice 7: (G) Italy
Choice 8: (H) Japan
Choice 9: (I) Romania
Choice 10: (J) Switzerland
Choice 11: (K) the United Kingdom
Choice 12: (L) null (if Country of Citizenship is U.S.)
Fill-in (7) Systems Generated
Choice 1: You
Choice 2: He
Choice 3: She
Fill-in (8) Requested As A Money Amount in Format $$$$$.¢¢
Amount of refund
Fill-in (9) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
TAX021 COA — TAX TREATY TO NONTAX TREATY COUNTRY (A82)
(Requested)
Caption: Your Benefits
We are deducting a Federal income tax from (1) your benefits each month. We did not deduct the tax before (2) because you were living in (3) . We will stop deducting the tax or deduct it at a lower rate if:
(4) a U.S. citizen,
OR
(5) in the United States, Canada, Egypt, Germany, Ireland, Israel, Italy, Japan, Romania, Switzerland or the United Kingdom.
(6)
Please let us know if any of these things happen.
Fill-in values:
Fill-in (1) Systems Generated
Choice 1: your
Choice 2: Beneficiary name Possessive
Fill- in (2) Systems Generated
Choice 1: you were
Choice 2: he was
Choice 3: she was
Fill-in (3) Requested As A One Position Alpha Character
Choice 1: (A) Canada
Choice 2: (B) Egypt
Choice 3: (C) Germany
Choice 4: (D) India
Choice 5: (E) Ireland
Choice 6: (F) Israel
Choice 7: (G) Italy
Choice 8: (H) Japan
Choice 9: (I) Romania
Choice 10: (J) Switzerland
Choice 11: (K) the United Kingdom
Fill- in (4) Systems Generated
Choice 1: You become
Choice 2: He becomes
Choice 3: She becomes
Fill- in (5) Systems Generated
Choice 1: You live
Choice 2: He lives
Choice 3: she lives
Fill-in (6) Request As A One Position Alpha Character
Choice 1: (A) Also, if you are a citizen and resident of India, all or part of your benefits can be exempt from this Federal income tax if your benefits are based on Federal, State or local government.
Choice 2: (B) Also, if he is a citizen and resident of India, all or part of his benefits can be exempt from this Federal income tax if his benefits are based on Federal, State or local government employment.
Choice 3: (C) Also, if she is a citizen and resident of India, all or part of her benefits can be exempt from this Federal income tax if her benefits are based on Federal, State or local government employment.
Choice 4 : (D) Null
TAX022 CHANGE IN TAX STATUS — NEW INFORMATION OR EVIDENCE SUBMITTED (A84)
(Requested)
Caption: Your Benefits
Because of the information (1) gave us, we are (2) deducting Federal income tax from (3) benefits. We do not deduct this tax or deduct it at a lower rate if (4) a U.S. citizen, or if (5) in the United States, Canada, Egypt, Japan, Romania, Ireland, Israel, Italy, Germany, Switzerland or the United Kingdom. (6) Please let us know if (7) (8) address again.
Fill-in values:
Fill-in (1) Systems Generated
Choice 1: you
Choice 2: Beneficiary's name
Fill-in (2) Requested As A One Position Alpha Character
Choice 1: (A) no longer
Choice 2: (B) now
Fill-in (3) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (4) Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (5) Systems Generated
Choice 1: you live
Choice 2: he lives
Choice 3: she lives
Fill-in (6) Systems Generated
Choice 1: Also, if you are a citizen and resident of India, all or part of your benefits can be exempt from this Federal income tax if your benefits are based on Federal, State or local government.
Choice 2: Also, if he is a citizen and resident of India, all or part of his benefits can be exempt from this Federal income tax if his benefits are based on Federal, State or local government.
Choice 3: Also, if she is a citizen and resident of India, all or part of her benefits can be exempt from this Federal income tax if her benefits are based on Federal, State or local government.
Fill-in (7) Systems Generated
Choice 1: you change
Choice 2: he changes
Choice 3: she changes
Fill-in (8) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
TAX023 ALIEN WITHHOLDING INCREASED TO 25.5 PERCENT (A85)
(Requested)
Caption: Your Benefits
We are deducting a Federal income tax of 25.5 percent from (1) Social Security benefit each month. This is because of a change in the United States Internal Revenue law which says that we must tax Social Security benefits at this higher rate.
Fill-in values:
Fill-in (1) Systems Generated
Choice 1: your
Choice 2: Beneficiary's name possessive
TAX024 REFERRAL TO IRS FOR QUESTIONS ABOUT TAX LIABILITY (A87)
(Requested)
Caption: Your Benefits
If (1) any further questions about (2) tax, please write to the Internal Revenue Service, Taxpayer Service Division, Washington, DC 20225.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you have
Choice 2: Beneficiary's name has
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
TAX025 NO CHANGE IN TAX STATUS — NEW INFORMATION OR EVIDENCE SUBMITTED (A89)
(Requested)
Caption: Your Benefits
We will continue to deduct a Federal income tax from (1) benefit each month. The new facts (2) gave us did not cause us to stop deducting the tax. We will stop deducting the tax or deduct it at a lower rate if:
(3) a U.S. citizen,
OR
(4) in the United States, Canada, Egypt, Germany, Ireland, Israel, Italy, Japan, Romania, Switzerland or the United Kingdom.
(5) Please let us know if any of these things happen
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your
Choice 2: Beneficiary's name possessive
Fill-in (2) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (3) - Systems Generated
Choice 1: you become
Choice 2: he becomes
Choice 3: she becomes
Fill-in (4) - Systems Generated
Choice 1: you live
Choice 2: he lives
Choice 3: she lives
Fill-in (5) - Systems Generated
Choice 1: Also, if you are a citizen and resident of India, all or part of your benefits can be exempt from this Federal income tax if your benefits are based on Federal, State or local government.
Choice 2: Also, if he is a citizen and resident of India, all or part of his benefits can be exempt from this Federal income tax if his benefits are based on Federal, State or local government.
Choice 3: Also, if she is a citizen and resident of India, all or part of her benefits can be exempt from this Federal income tax if her benefits are based on Federal, State or local government.
TAX026 OVERPAYMENT INCLUDES AMOUNTS WITHHELD FOR NONRESIDENT ALIEN TAX - OVERPAID PERSON IN NONPAY STATUS - NO CROSS PROGRAM ADJUSTMENT (A91)
(Requested)
Caption: Your Benefits
(1) total overpayment is (2) . This includes the Federal income tax we deducted from the benefits (3) not due.
When (4) us back, (5) (6) . We will use the tax we deducted from (7) check to get back the rest of the overpayment.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Your
Choice 2: Beneficiary's name possessive
Fill-in (2) Requested As A Money Amount in Format $$$$$.¢¢
Amount
Fill-in (3) - Systems Generated
Choice 1: you were
Choice 2: he was
Choice 3: she was
Fill-in (4) - Systems Generated
Choice 1: you pay
Choice 2: he pays
Choice 3: she pays
Fill-in (5) - Systems Generated
Choice 1: you only need to repay
Choice 2: he only needs to repay
Choice 3: she only needs to repay
Fill-in (6) Requested As A Money Amount in Format $$$$$.¢¢
Amount
Fill-in (7) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
TAX027 WITHHOLDING TAX (DOE 12/83 OR LATER) (G27)
(System Generated)
Caption: Your Benefits
We are deducting Federal income tax from (1) benefit each month (2) (3) . We will stop deducting the tax or deduct it at a lower rate if:
(4) (5) a U.S. citizen, or
(6) (7) in the United States, Canada, Egypt, Germany, Ireland, Israel, Italy, Japan, Romania, Switzerland or the United Kingdom
Also, if an individual is a citizen and resident of India, all or part of that person's benefits can be exempt from this Federal income tax if those benefits are based on Federal, State or local government employment.
Please contact us if any of these things happen.
We collect this tax for the Internal Revenue Service. So, if you disagree with the decision to tax (8) , you will have to contact them to appeal. However, if you think we made a mistake about where (9) (10) or about (11) citizenship, let us know. We will correct the mistake.
Fill-in values:
Fill-in (1)
Choice 1: Beneficiary's Name Possessive
Choice 2: your
Fill-in (2)
Choice 1: null
Choice 2: beginning
Fill-in (3)
Choice 1: MM/CCYY
Choice 2: null
Fill-in (4)
Choice 1: she
Choice 2: he
Choice 3: you
Fill-in (5)
Choice 1: become
Choice 2: becomes
Fill-in (6)
Choice 1: she
Choice 2: he
Choice 3: you
Fill-in (7)
Choice 1: live
Choice 2: lives
Fill-in (8)
Choice 1: Beneficiary's Name
Choice 2: you
Fill-in (9)
Choice 1: Beneficiary's Name
Choice 2: you
Fill-in (10)
Choice 1: live
Choice 2: lives
Fill-in (11)
Choice 1: her
Choice 2: his
Choice 3: you
TAX050 COA — FOREIGN TO DOMESTIC — BENEFICIARY SUBJECT TO ALIEN TAX UNTIL RESIDENCE IN U.S. ESTABLISHED (A80)
(Requested)
Caption: Your Benefits
We are deducting Federal income tax from (1) benefits because our records show that (2) . We may stop deducting the tax if (3) of the U.S. Please get in touch with a Social Security office if (4) .
Fill-in values:
Fill-in (1) Systems Generated
Choice 1: your
Choice 2: Beneficiary name possessive
Fill-in (2) Systems Generated
Choice 1: you are not a U.S. citizen or resident
Choice 2: he is not a U.S. citizen or resident
Choice 3: she is not a U.S. citizen or resident
Fill-in (3) Systems Generated
Choice 1: you become a resident
Choice 2: he becomes a resident
Choice 3: she becomes a resident
Fill-in (4) Systems Generated
Choice 1: you become a resident
Choice 2: he becomes a resident
Choice 3: she becomes a resident