BASIC (07-90)

Social Security Administration

Retirement, Survivors, and Disability Insurance

Notice of Award

                                                                                        Miscellaneous Program Service Center

                                                                                       225 E. Oak Street

                                                                                       Central City, ST 00000

                                                                                       Date:

                                                                                       Claim Number: 123-45-6789A

JOHN G. BENEFICIARY

101 MAIN STREET

ANYTOWN, ST 00001

You are entitled to monthly retirement benefits beginning February 1989.

What We Will Pay And When

• You will receive $286 for February 1989 around March 3, 1989.

• After that you will receive $286 each month.

Other Social Security Benefits

The benefits described in this letter is 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.

Do You Think We Are Wrong?

If you think we are wrong, you have the right to appeal. We will correct any mistakes and will look at any new facts you have. A person who did not make the first decision will decide your case.

• You have 60 days to ask for an appeal.

• The 60 days start the day after you get this letter.

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

Your Responsibilities

Your benefits are based on the information you gave us. If this information changes, it could affect your benefits. For this reason, it is important that you report changes to us right away.

We have enclosed a pamphlet, “Your Social Security Rights and Responsibilities.” It tells you what you must be reported and how to report. Please be sure to read the part of the pamphlet which explains how work could changes your payments.

If You Have Any Questions

If you have any questions, you may call us at 1-800-2345-SSA. We can answer most questions over the phone. You can also write any Social Security office. The office that serves your area is located at:

                                               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 at the office. This will help us serve you more quickly when you arrive at the office.

                                                                                 Gwendolyn S. King

                                                                                 Commissioner

                                                                                      of Social Security

Enclosure(s):

Pub 05-10077