BBA 812 - Model Response - For Section 1129 of the Act

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].