We sent you $ (1) more in Social Security benefits for (2) than we should have.

(3) .

As representative payee, you are personally liable for repayment unless you used the overpaid funds for the benefit of (4) and the overpayment was made through no fault of your own.

How To Pay Us Back

3103A

or

3104B

or

3102B

 

If You Think You Should Not Have To Pay Us Back

3100C

 

If You Disagree With The Decision

3108B

Enclosures:

SSA-3105

Refund envelope¹

 

¹ If the overpayment is less than the monthly payment, omit the refund envelope.

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

• •

  Use 3103A if the overpayment exceeds the monthly payment.

• •

  Use 3104B if the overpayment equals the monthly payment.

• •

  Use 3102B if the overpayment is less than the monthly payment.

• •

  Use 3100C and 3108B in all cases.

   

Refer to NL 00703.102 for 3102B text and fill-ins and NL 00703.103 for 3103A text and fill-ins. Refer to NL 00703.100 for 3100C text and fill-ins. Refer to NL 00703.108 for 3108B text. Refer to NL 00703.104 for 3104B text and fill-ins.

Fill-ins:

1. (1) 

   amount of the overpayment (not including taxes withheld)

2. (2) 

   names of beneficiary(ies)

3. (3) 

   narrative overpayment explanation - A chart may be included following the explanation.

4. (4) 

   name(s) of beneficiary(ies)

Use Form SSA-L2000-C2 (Universal Notice) and follow the notice standards. Information for this notice will be shown on Form SSA-573.