Basic (06-81)

GN 02280.915 Sample Guide — Notice To Representative Payee For Beneficiary With Title XVIII Overpayment Who Is Currently Receiving Benefits For Beneficiary -Adjustment Proposed - No Waiver Offered

(Name of beneficiary) was previously informed that (he/she) has been overpaid $        by the Medicare Program. The Social Security law requires that we recover the overpayment by withholding the amount from the social security benefits you receive for (him/her) .

We plan to withhold $        each month beginning with the benefit you will receive for (name of beneficiary) in (month/year) . This will reduce (his/her ) payment to $        a month. We will continue withholding from the benefit you receive for (name of beneficiary) each month until (his/her) overpayment has been fully recovered.

Please call, write or visit any social security office if (1) (name of beneficiary) cannot afford the planned reduction of (his/her) benefit and you would like to request that less of (his/her) monthly benefit be withheld; or (2) you would like more of the monthly benefit withheld so that the overpayment can be paid back sooner; or (3) you would prefer to make full refund of the overpayment so that no withholding of the monthly benefit is necessary. Please take this letter with you if you do visit a social security office. Unless we hear from you within 30 days, we will reduce (his/her) benefit as shown above.