ACT034 – PRIVACY ACT STATEMENT COLLECTION AND USE OF PERSONAL STATEMENT

Privacy Act Statement

Sections 204 and 1631 of the Social Security Act, as amended, allow us to collect this information, which we will use to process your payment. Providing the information is voluntary, but not providing all or part of the information may prevent us from processing your payment. As law permits, we may use and share the information you submit, including with banks enrolled in the Treasury credit card network, to collect a payment or debt when the individual has given us his or her credit number for this purpose, and third party contacts such as private collection agencies and credit reporting agencies under contract with the Social Security Administration and other agencies, for assistance with recovering program debt, as outlined in the routine uses within System of Records Notice 60-0094, available at www.ssa.gov/privacy. The information you submit may also be used in computer matching programs for Federal benefits eligibility and to recoup debts under these programs.

ADJ048 – UNDERPAYMENT TRANSFERRED FROM DECEASED BENEFICIARY TO SPOUSE

You will soon receive a payment of (1) because we owed money to (2). This payment is in addition to any monthly payments you may receive.

AETC02 – CAPTION

You May Be Due More Benefits

AETC06 – CAPTION

What We Will Do

AETC07 – CAPTION

The Yearly Earnings Limit

AETC08 – CAPTION

A Special Rule That Applies To Earnings In One Year

AETC09 – CAPTION

If Your Expected Earnings Change

AETC10 – CAPTION

If You Work For Wages

AETC11 – CAPTION

If You Are Self-Employed

AETC12 – CAPTION

If You Work For Wages and Are Self-Employed

AETC14 – CAPTION

How We Calculate Earnings

If You Work For Wages and Are Self-Employed

AETH01 – HEADER

How Work Affects Your Social Security

AETH02 – HEADER

How To Estimate Earnings

AET036 – INFORMATIONAL PARAGRAPH TO THE BENEFICIARY ABOUT HOW EARNINGS HAVE AFFECTED HIS OR HER SOCIAL SECURITY BENEFITS

Please read the rest of this letter carefully. In it, we explain the changes we are making to your benefits. We also tell you how your earnings have affected your benefits and what to do if you disagree with any of our decisions.

AET037 – REFER TO WORKSHEET HEADER NL 00730.149D

The amount you (1) above the allowed amount is (2)

AET038 – PROVIDES THE LAST MONTHLY EARNINGS TEST YEAR’S INCOME LIMITS AND THE BENEFICIARY'S NON-SERVICE MONTHS FOR THE LAST MONTHLY EARNINGS TEST YEAR

In addition, you told us that you did not (1) more than (2) a month and did not work over 45 hours a month in self-employment (3) (4).

AET039 – INTRODUCTORY PARAGRAPH FOR THE BENEFICIARY ABOUT THE ANNUAL EARNINGS LIMIT FOR SPECIFIC YEARS

The earnings limit for (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11). If you over the allowed amount for the year, we withhold $1 in benefits for every (12) above the limit. We have enclosed a worksheet to show how we applied the earnings limit to your earnings to figure your benefits.

For more information about the earnings limit, see the enclosed fact sheet called, "How Work Affects Your Social Security."

AET040 – PARAGRAPH TO A NON-RESPONDER (NRP) WITH A MID-YEAR MAILER INDICATOR ON THE MASTER BENEFICIARY RECORD (MBR) EXPLAINING THAT SINCE HE OR SHE DID NOT PROVIDE AN ESTIMATE OF EARNINGS FOR THE CURRENT YEAR, WE WILL USE LAST YEAR'S EARNINGS AS THE CURRENT YEAR ESTIMATE

Earlier we asked you to estimate earnings for (1). We need this estimate to decide how much Social Security benefits to pay for (2). We have not heard from you. Unless you contact us with a new estimate, we will use the same estimate we used in (3) to decide benefits for (4).

AET041 – PARAGRAPH TO A NON-RESPONDER (NRP) WITH NO MID-YEAR MAILER INDICATOR ON THE MASTER BENEFICIARY RECORD (MBR) EXPLAINING THAT SINCE HE OR SHE DID NOT PROVIDE AN ESTIMATE OF EARNINGS FOR THE CURRENT YEAR. WE WILL USE LAST YEAR’S EARNINGS AS THE CURRENT YEAR ESTIMATE.

We base the amount of Social Security benefits you are due on your estimated earnings. In (1), your earnings estimate was (2). Unless you contact us with a new estimate, we will use that same estimate to decide your benefits for (3).

AET042 – PARAGRAPH TO A WORKING BENEFICIARY THAT SINCE HE OR SHE DID NOT PROVIDE AN ESTIMATE OF EARNINGS FOR THE CURRENT YEAR, WE WILL USE THE EARNINGS REPORTED BY HIS OR HER EMPLOYER LAST YEAR AS THE CURRENT YEAR ESTIMATE.

In (1), we based the amount of your Social Security benefits on earnings of (2) that your employer reported. We will use the same amount of earnings to decide your benefits in (3). That is, unless you contact us with a new estimate of your expected earnings for (4).

AET043 – REQUEST TO BENEFICIARY ASKING THEM TO NOTIFY SOCIAL SECURITY ADMINISTRATION IF HIS OR HER WORK ESTIMATE IS NOT CORRECT

Your work plans may have changed and we want to make sure that we are paying you correctly. So, please check your estimate, and let us know right away if you think (1) will earn more or less than (2) in (3).

AET044 – EXPLAINS TO A DIVORCED AUXILIARY SPOUSE THAT A FORMER SPOUSE'S WORK NO LONGER AFFECTS BENEFITS

You told us your divorce was final in (1). Once you have been divorced for 2 years, your former spouse’s work no longer affects your benefits. Therefore, beginning (2), we will no longer withhold or reduce your benefits because of former spouse's work.

AET045 – REFER TO WORKSHEET HEADER NL 00730.149A

AET046 – REFER TO WORKSHEET HEADER NL 00730.149A

AET047 – REFER TO WORKSHEET HEADER NL 00730.149A

AET048 – REFER TO WORKSHEET HEADER NL 00730.149B

AET049 – REFER TO WORKSHEET HEADER NL 00730.149B

AET050 – REFER TO WORKSHEET HEADER NL 00730.149B

AET051 – REFER TO WORKSHEET HEADER NL 00730.149D

AET052 – REFER TO WORKSHEET HEADER NL 00730.149D

AGE018 – EXPLANATION OF FULL RETIREMENT AGE (FRA) ATTAINMENT WHEN BORN ON THE FIRST DAY OF THE MONTH

Because you were born on the first day of the month, we consider you (1) the month before.

ALSC04 – CAPTION

If You Disagree With The Decision

ALSC06 – CAPTION

Do You Think We Are Wrong About The Overpayment

ALSC37 - CAPTION

You Have the Right To Request a Reconsideration

ALS017 – APPEALS LANGUAGE FOR MONTHLY BENEFIT PAYABLE (MBP) CHANGE DUE TO A THIRD-PARTY ACTION

If you disagree with the change we have made to your) monthly payment, you have the right to appeal. We will review your case and look at any new facts you have. A person who did not make the first decision will decide your case.

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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. We assume you got this letter 5 days after the date on it unless you show us that you did not get it within the 5-day period.

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  You must have a good reason for waiting more than 60 days to ask for an appeal.

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  You have to ask for an appeal in writing. We will ask you to sign a Form SSA-561-U2, called "Request for Reconsideration". Contact one of our offices if you want help.

ALS020 – GENERAL APPEALS LANGUAGE

If you do not agree with this decision, you have the right to appeal. We will review your case and look at any new facts you have. A person who did not make the first decision will decide your case. We will review the parts of the decision that you think are wrong and correct any mistakes. We may also review the parts of our decision that you think are right. We will make a decision that may or may not be in your favor.

ALS100 – PAYMENTS WILL CONTINUE WHILE THE APPEAL OF MEDICAL CESSATION IS PENDING

You are entitled to have your payments continued until we notify you of the appeal decision made on your case. If you lose your appeal, you may have to pay some, or all, of this money back unless we are able to waive repayment

ALS165 – APPEAL RIGHTS AND PROCESS FOR NON-MEDICAL PREMIUM DECISIONS

The appeal rights described in the section do not apply to Medicare premium adjustments. If you have questions about your Medicare premium adjustment, please call toll-free (1-800-633-4227). If you are deaf or heard of hearing, you may call the Medicare TTY number toll-free at 1-800-486-2048.

If you disagree with the decision, other than the adjustment to your Medicare premium, you have the right to appeal. We will review your case and consider any new facts you have. A person who did not make the first decision will decide your case. We will correct any mistakes. We will review those parts of the decision which you believe are wrong and will look at any new facts you have. We may also review those parts which you believe are correct and may make them unfavorable or less favorable to you.

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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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  We assume you got this letter 5 days after the date on it unless you show us that you did not get it within the 5-day period.

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  You must have a good reason for waiting more than 60 days to ask for an appeal.

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  You have to ask for an appeal in writing. We will ask you to sign a Form SSA-561-U2, called "Request for Reconsideration". Contact one of our offices if you want help.

ALS217 - RIGHT TO APPEAL THE OVERPAYMENT

If you do not agree with this determination, you have the right to appeal. Notify us promptly if you would like to request a reconsideration. We will review the case and look at any new facts you have. A person who did not make the first decision will decide the case. If you appeal, we will not collect the overpayment until we notify you of our appeal determination. We will review the entire determination and correct any mistakes. We may also review those parts of the case that you believe are correct and make them unfavorable or less favorable to you. We will make a determination that may or may not be in your favor.

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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 receive this letter. We assume you received this letter 5 days after the date on it unless you show us that you did not receive it within the 5-day period.

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  You must have a good reason for waiting more than 60 days to ask for an appeal.

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  You must ask for an appeal in writing. Please use our “Request for Reconsideration” form, SSA-561.

The fastest and easiest way to file an appeal is to visit https://www.ssa.gov/non-medical/appeal online. Alternatively, you can complete and submit the "Request for Reconsideration" form, SSA-561. You may go to our website at https://www.ssa.gov/forms/ssa-561.html to find the form SSA-561. Customers with an online Social Security account can now submit some documents electronically to us. Create or sign in to your my Social Security account at https://www.ssa.gov/myaccount and select “Upload Documents.” You can also contact us by phone, mail, or come into an office to request the form. You may also submit the form by mail or in person to your local SSA field office. The field office’s mailing address is available through SSA’s website at https://www.ssa.gov/locator/. If you need help filling out and submitting the form, we can help you by phone or in person.

 

ANP003 – BENEFICIARY OUTSIDE U.S. (Pub-05-10137)

Please refer to the Publication section of this notice to access the pamphlet, "Social Security: Your Payments While You Are Outside the United States." It explains what you will need to do to start receiving payments again.

APP046 – Paragraph

If you file an application, we will review the claim and make a decision. If you do not agree with what we decide, you will be able to appeal the decision.

ASTC02 – CAPTION

Information About Your Installment Payment

ATYC01 – CAPTION

Information About Representatives Fees

ATYC03 – CAPTION

Information About Past-Due Benefits Withheld To Pay A Representative

ATY067 – SUPPLEMENTAL SECURITY INCOME OFFSET HAS BEEN DETERMINED – PAST DUE BENEFITS BEING RELEASED TO BENEFICIARY AND REPRESENTATIVE HAS NOT REGISTERED FOR DIRECT PAYMENT

If a representative, who is a (1), registers with us to receive direct fee payment, because of the law we usually withhold part of the past-due benefits to pay the fee we approve. Although your representative is a (2), he or she did not register for direct payment before we completed our work on your claim. For that reason, we did not withhold from your past-due benefits to pay the fee we approve. Therefore, the Social Security Administration is not involved in paying the fee. This is a matter between you and your (3).

ATY836 – EXPLANATION TO THE BENEFICIARY ABOUT THE WITHHOLDING OF REPRESENTATIVE FEES FROM PAST-DUE BENEFITS

Based on the law, we must withhold part of past-due benefits to pay an appointed representative. We cannot withhold more than 25 percent of past-due benefits to pay an authorized fee. We withheld (1) from your past-due benefits to pay your representative.