20 CFR 404.1503b(c) & 416.903b(c)

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].