Basic (06-81)

GN 02280.940 Sample Guide — Notice To Other Beneficiary - Recovery From Overpaid Person Not Possible

Our records show that (overpaid person's name) received $         more in (social security/Medicare) benefits than (he /she) was due. (Explain in simple, nontechnical terms how and when this overpayment occurred.)

When the overpaid person is deceased and the overpayment has not been recovered, the overpayment may be withheld from any other benefits payable on the same social security record on which the overpaid person had received benefits. Since you are receiving monthly benefits on the same record as (name of overpaid person) , we plan to withhold $        each month beginning with the benefit you will receive in (month/year) . This will reduce your payment to $        a month. We will continue withholding from your benefit each month until the overpayment has been fully recovered.

You have certain rights with respect to this overpayment and our proposed reduction of your benefit.

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 this overpayment. The overpayment must be withheld from your benefits unless it is determined that all of the following are true:

   1. A. 

      The overpayment was not your fault, and

   2. B. 

      The overpayment was not the fault of (name of overpaid person), and

   3. C. 

      You couldn't meet your 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 your assets and monthly income and expenses.

If you request reconsideration and/or waiver within 30 days, the planned reduction of the benefit(s) to recover the overpayment will not take place until your case is reviewed. This review is described in more detail as a “Preadjustment Review” on the attached Form SSA-3105, Important Information About Your Review Rights. The people in any social security office will be glad to help you complete the forms for requesting reconsideration (SSA-5611, Request for Reconsideration) and/or waiver (SSA-632-F4, Overpayment Recovery Questionnaire).

Even if you do not want to request reconsideration or waiver, please call, write, or visit any social security office, if you cannot afford the planned reduction in your benefits or if you would like more of your benefit withheld so that the overpayment can be paid back faster. Please take this letter with you if you do visit an office. Unless we hear frm you within 30 days, we will reduce your benefit as shown above.

Enclosures: SSA-3105