[Your Name] [Your Address]
Request for Reconsideration
[address on decision letter]
[date that you've written letter]
Dear Sir/Madam
Request for Reconsideration
National Insurance Number: [your National Insurance Number]
Decision in respect of [the name of the benefit you've been refused]
Decision Dated: [the date on the decision letter]
I would like you to look again at your decision as above, as I think that it is wrong. The reasons why I disagree with the decision are as follows:
[the reasons why you disagree]
I include the following extra evidence for you to take into consideration: [included any other extra evidence if you have it]
Thank you for your assistance. If you have any questions please contact me on [your phone number].
Yours faithfully
[sign here]
[print your name]