No payments can be made to you beginning (1) because notice has been received that

(2) , on whose Social Security record your benefit is based, is working outside the United States (U.S.) more than 45 hours per month. No further benefits may be paid to you until (3) completes a request for benefits payable form and sends it to this office.

We have determined that you received $ (4) more in Social Security benefits than you were due. You received payment(s) for (5) to which you were not entitled.

3106E

3100FC

3106A (Optional)

You have certain rights with respect to this overpayment and its recovery.

1. 1. 

   Right to appeal: If you disagree in any way with this overpayment determination, you have the right, within 60 days of the date you receive this notice, to request that the determination be reconsidered. If you request this independent review of the overpayment determination, please submit any additional information you have which pertains to the overpayment.

2. 2. 

   Right to request waiver: You also have the right to request a determination concerning the need to recover the overpayment. An overpayment must be refunded or withheld from benefits unless both of the following are true:

   1. a. 

      The overpayment wasn't the person's fault in any way, and

   2. b. 

      The person couldn't meet necessary living expenses if we recovered the overpayment, or recovery would be unfair for some other reason.

If you request waiver, we may need a statement of assets and monthly income and expenses.

If you request reconsideration and/or waiver within 30 days, the overpayment will not have to be recovered until the case is reviewed. This review is described in more detail on the attached Form SSA-3105, Important Information About Your Appeal and Waiver Rights. No provision has been made for personal conferences to be held outside the U.S.; therefore, you or your representative would have to come to the U.S. at your own expense to attend the personal conference. The people in any Social Security office will be glad to help you complete the forms for requesting reconsideration (SSA-561-U2, Request For Reconsideration) and/or waiver (SSA-632-BK, Request for Waiver of Overpayment Recovery or Change in Repayment Rate).

Persons who live in the Philippines should contact the Veterans Affairs Regional Office, SSA Division, 1131 Roxas Boulevard, Manila. All other persons may contact the nearest U.S. embassy or consulate. If you prefer, you may write to us at Post Office Box 17769, Baltimore, Maryland 21235-0001, U.S.A.

Even if you do not want to request reconsideration or waiver, please call, write, or visit if you have any questions or need more information. Please take this letter with you if you do visit an office.

 

Enclosures:

SSA-3105

Refund Envelope

• •

  The person who determines the overpayment (generally the benefit authorizer) is responsible for requesting this notice and providing the appropriate fill-ins.

• •

  See NL 00703.100 for text of 3100FC.

• •

  Use fill-in 3106A if the liable individual is receiving other program payments (e.g., a person liable for repayment of a title II overpayment receives Black Lung payments.) See NL 00703.106 for text and fill-ins.

   

Fill-ins:

1. (1) 

   month/year

2. (2) 

   number holder's name

3. (3) 

   number holder's name

4. (4) 

   amount of overpayment

5. (5) 

   month(s)/year(s)

Use SSA-L2000-C2 (Universal Notice). Include a “refund envelope” with the letter and type the claim number on the inside of the envelope below the flap. Place the envelope lengthwise on the left-hand side of the notice, and staple the upper left-hand corner.

Because the fill-ins may vary according to the different situations, follow the requester's typing instructions carefully.