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20 CFR 416.903b(c) - Follow-up Notice
ICR 202607-0960-007 · OMB 0960-0803 · Object 170782600.
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Document Metadata
| File Type | application/pdf |
|---|---|
| File Title | 20 CFR 416.903b(c) - Follow-up Notice |
| Author | ALC |
| Last Modified By | Microsoft® Word 2010 |
| File Modified | 2016-09-20 |
| File Created | 2016-08-15 |
| Conversion State | complete |
Extracted Text
WRITTEN STATEMENT REGARDING SECTION 223(d)(5)(C) OF THE SOCIAL SECURITY ACT – DO NOT REMOVE I, [Name and Title], was imposed with a civil monetary penalty, an assessment, or both, for submitting false evidence, under section 1129 of the Social Security Act, on [Date of Final Decision imposing Civil Monetary Penalty, Assessment, or Both].