BASIC (07-90)

Social Security Administration

Retirement, Survivors, and Disability Insurance

Notice of Disapproved Claim

                                                                                           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

We have considered your application and find that you are not entitled to any Social Security benefits.

Why We Cannot Pay You

You do not qualify for retirement benefits now because, based on your correct date of birth was, January 17, 1927, you are not yet age 62.

Your Date of Birth

Based on the evidence we have, we have decided that your correct date of birth was January 17, 1927.

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 you get this letter.

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

Other Social Security Benefits

You are not entitled to any other Social Security benefits based on the application you filed. In the future, if you think you may be entitled to benefits, you will need to apply again.

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.

                                                                                            Social Security Administration