BASIC (07-90)

Social Security Administration

Retirement, Survivors, and Disability Insurance

Claim Information

                                                                                          Miscellaneous Program Service Center

                                                                                         225 E. Oak Street

                                                                                         Central City, ST 00000

                                                                                         Date:

                                                                                        Claim Number: 123-45-6789A

JASON SMITH

1010 MAIN STREET

ANYTOWN, ST 00001

We cannot process the application you filed for Social Security benefits on behalf of JOHN G. BENEFICIARY because you are not the proper person to apply for benefits on Mr. BENEFICIARY’S behalf.

If You Have Any Questions

If you have any question, 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