Use this notice to when beneficiary or recipient fails to make the monthly payment based on a signed repay agreement. The beneficiary or recipient will have a specific amount of time to adhere to the agreement before the Agency send the case to the Office of the Inspector General or the United States Secret Service for prosecution. The notice is available in the Document Processing System.

We are writing to you about your agreement to repay us [1] for [2] [3] checks you cashed after [4] death.

Your Agreement

You agreed to repay [5] each month until the total amount of [6] is paid back.

What Our Records Show

We have not received the [7] payment that was due by [8]. If you cannot send us the payment by [9], please get in touch with us. If you have already sent this payment, please disregard this request.

If We Do Not Hear From You

If you do not pay us or get in touch with us about this by [10], we will consider sending this case to the Office of the Inspector General or the United States Secret Service for prosecution.

If You Have Any Questions

If you have any questions, you may call us at 1-800-772-1213, or call your local Social Security office at [11]. We can answer most questions over the phone. You may also write or visit any Social Security office. The office that serves your area is located at: [12]

If you do call or visit an office, please have this letter with you. It will help us answer your questions. If you plan to visit an office, you may want to call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

Social Security Administration
Retirement, Survivors and Disability Insurance
Important Information

100 East Capitol St. SE
Washington, DC 20019

Phone: (202) 555-5555

Office Hours: 8:30 a.m. until 5:00 p.m.

Date:

Claim Number: 123-00-6789A

Mrs. Jane Doe
103 Main Street
Washington, DC 20019

We are writing to you about your agreement to repay us $500 for John Doe's Supplemental Security Income checks you cashed after his death.

Your Agreement

You agreed to repay $100 each month until you repaid us the total amount of $500.

What Our Records Show

We have not received the $100 payment that was due by December 1, 2000. If you cannot send us the payment by December 31, 2000, please get in touch with us. If you have already sent this payment, please disregard this request.

If We Do Not Hear From You

If you do not pay us or get in touch with us about this by XX/XX/XX, we will consider sending this case to the Office of the Inspector General or the United States Secret Service for possible prosecution.

If You Have Any Questions

If you have any questions, you should call, write or visit any Social Security office. If you call or visit our office, please have this letter with you and ask for Sallie Claims rep. The telephone number is at the top of page 1. We can answer most questions over the phone. If you plan to visit an office, you may want to call ahead to make an appointment. This will help us serve you more quickly.

Field Office Manager

Enclosure:

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