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                  1.  
                     Sample Notice When Good Cause Not Found 
 
 
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                  2.  
                     Sample Notice for Liable Sponsor 
 
 
                                    Example 1
         Social Security Administration
         Supplemental Security Income
         Notice of Overpayment
                                 Date: August 24, 1988
                                 Claim Number: XXX-XX-XXXX
         Name
 Street Address
 City/State/Zip Code
         
          
         We are writing to you about the SSI recipient's overpayment of $125.00. You asked
            that we not make you pay this money back. We decided that you do have to pay back
            the overpayment.
         
         THE REASON FOR OUR DECISION
         We said that you did not have to pay back the overpayment if you had a good reason
            for not reporting the increase in your earnings. Base on the facts you gave us, we
            decided not a good reason. This is because we told you that you must report any changes
            in your earnings.
         
         DO YOU THINK WE ARE WRONG?
         If you think we are wrong, you have the right to appeal. We will correct mistakes.
            We will look at any new facts you have.
         
         
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                  • 
                     You have 60 days to ask for an appeal. 
 
 
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                  • 
                     The 60 days start the day after you get this letter. 
 
 
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                  • 
                     You will have to have a good reason for waiting more than 60 days to ask for an appeal. 
 
 
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                     To appeal, you must fill out a form call “Request for Reconsideration.” The form number is SSA-561. To get this form, contact, contact one of our offices.
                        We can help you fill out form.
                      
 
 
HOW TO APPEAL
         There are three ways to appeal.  You can pick the one you want. If you meet with us
               in person, it may help us decide your case .
         
                                          Example 1(cont.)
                                          xxx-xx-xxxx
         08/24/88                               Page 2
          
         
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                      Case Review . You have a right to review the facts in your file. You can give us more facts to
                        add to your file. Then we will decide your case again. You will not meet with the
                        person who decides your case.
                      
 
 
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                  • 
                      Informal Conference . You will meet with the person who decides your case. You can tell that person why
                        you think you are right. You can give us more facts to help prove your are right.
                        You can bring other people to help explain your case.
                      
 
 
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                  • 
                      Formal Conference . This is a meeting like an information conference. The difference is we can make
                        people come to help prove you are right. We can make them bring important papers about
                        your case, even if they do not want to help you. You can question these people at
                        your meeting.
                      
 
 
IF YOU WANT HELP WITH YOUR APPEAL
         You may want help from a friend, lawyer or someone else. There are groups that can
            find you a lawyer. Some can give you a free lawyer. We can give you the means of these
            groups.
         
         HOW TO PAY US BACK
         There are two ways you can pay us back.
         
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                  • 
                     You can send us a check or money order for the full amount of the overpayment of $125.00.
                        Make your check or money order out to the Social Security Administration. Be sure
                        to put the recipient's Social Security on it. Please use the enclosed envelope to
                        mail the check or money order to us. Also, be sure to enclose the payment stub with
                        your check or money order.
                       OR 
 
 
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                  • 
                     If you cannot send us the full amount now, send as much as you can. Then contact any
                        Social office. You can pay the rest of the money you owe by making monthly payments.
                      
 
 
If you cannot pay us in full, please contact us by September 26, 1988. You will need
            to tell us how you plan to pay us back.
         
                                         Example 1(cont.)
                                         xxx-xx-xxxx
         08/24/88                              Page 3
          
         If you do not pay back this money, we must withhold it from any future Social Security
            or SSI benefits that you may receive.
         
         IF YOU HAVE ANY QUESTIONS
         If you have any questions, you may call, write or visit any Social Security office.
            If you call or visit our office, please have this letter with you and ask for a representative.
            The telephone number is (111) 111-1111.
         
         Also, if you plan to visit an office, you may call ahead to make a appointment. This
            will help us serve you more quickly when you arrive at the office.
         
                              Name
                              District/Branch Manager
          
         Enclosures:
         — Detailed Explanation of Overpayment
 — Payment Stub
 — Refund Envelope
         
                                              Example 2
         Social Security Administration
         Supplemental Security Income
         Notice of Overpayment
                                    Date: January 12, 1989
                                    Claim Number: XXX-XX-XXXX
         Name
 Street Address
 City/State/Zip
         
         We are writing to let you know that we have paid the SSI recipient $125.00 too much
            Supplemental Security Income (SSI) money. The overpayment happened from October 1987
            through November 1987.
         
         The SSI recipient is an alien you sponsored to admission to the United States and
            agree to support. They were overpaid because you did not report your earnings. Therefore,
            you must pay back the overpayment, or we must withhold it from any future Social Security
            or SSI benefits that you may receive.
         
         Later in this letter, we will give you a detailed explanation of the overpayment.
         You must pay us back unless we are wrong about he overpayment or we decide you should
            not have to pay us back. This letter tells you what you can do if you thing we are
            wrong about the overpayment, or if you think you should not have to pay us back.
         
         IF YOU THINK YOU SHOULD NOT HAVE TO PAY US BACK
         You may not have to pay us back if you had a good reason for not telling us about
            your earnings. If you think that you had a good reason, let us know. You will not
            have to pay us back while we are deciding your case.
         
         DO YOU THINK WE ARE WRONG?
         If you think we are wrong, you have the right to appeal. We will correct mistakes.
            We will look at any new facts you have.
         
         
            - 
               
                  • 
                     You have 60 days to ask for an appeal. 
 
 
- 
               
                  • 
                     The 60 days start the day after you get this letter. 
 
 
- 
               
                  • 
                     You will have to have a good reason for waiting more than 60 days to ask for an appeal. 
 
 
                                Example 2(cont.)
                                          xxx-xx-xxxx
         01/12/89                              Page 2
          
         
            - 
               
                  • 
                     To appeal, you must fill out a form call “Request for Reconsideration.” The form number is SSA-561. To this form, contact one of our offices. We can help
                        you fill out the form.
                      
 
 
HOW TO APPEAL
         There are three ways to appeal.  You can pick the one you want. If you must with us
               in person, it may help us decide your case .
         
         
            - 
               
                  • 
                      Case Review . You have a right to review the facts in your file. You can give us more facts to
                        add to your file. Then we will decide your case again. Yo will not meet with the person
                        who decides your case.
                      
 
 
- 
               
                  • 
                      Informal Conference . You will meet with the person who decides your case. You can tell that person why
                        you think you are right. You can give us more facts to help prove your are right.
                        You can bring other people to help explain your case.
                      
 
 
- 
               
                  • 
                      Formal Conference . This is a meeting like an information conference. The difference is we can make
                        people come to help prove you are right. We can make them bring important papers about
                        your case, even if they do not want to help you. You can questions these people at
                        your meeting.
                      
 
 
IF YOU WANT HELP WITH YOUR APPEAL 
         You may want help from a friend, lawyer or someone else. There are groups that can
            find you a lawyer. Some can give you a free lawyer. We can give you the names of these
            groups.
         
         HOW TO PAY US BACK
         There are two ways you can pay us back.
         
            - 
               
                  • 
                     You can send us a check or money order for the full amount of the overpayment of $125.00
                        Make your check or money order out to the Social Security Administration. Be sure
                        to put the SSI recipient's Social Security number on it. Please use enclosed envelope
                        to mail the check or money order to us. Also, be sure to enclose the payment stub
                        with your check or money order.
                      
 
 
                                 Example 2(cont.)
                                          xxx-xx-xxxx
         01/12/89                               Page 3
          
          OR
         
            - 
               
                  • 
                     If you cannot send us the full amount now, send as much as you can. Then contact any
                        Social Security office. You can pay the rest of the money you owe by making monthly
                        payments.
                      
 
 
If you cannot pay us in full, please contact us by February 13, 1989. You will need
            to tell us how you plan to pay us back.
         
         If you do not pay back this money, we must withhold it from any future Social Security
            or SSI benefits that you may receive.
         
         IF YOU HAVE ANY QUESTIONS
         If you have any questions, you may call, write or visit any Social Security office.
            If you call or visit our office, please have this letter with you and ask for a representative.
            The telephone number is (111) 111-1111.
         
         Also, if you plan to visit an office, you may call ahead to make an appointment. This
            will help us serve you more quickly when you arrive at the office.
         
                                    Name
                                    District/Branch Manager
         Enclosures:
  
 —Detailed Explanation of Overpayment
 —Payment Stub
 —Refund Envelope