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1.
Sample Notice When Good Cause Not Found
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2.
Sample Notice for Liable Sponsor
Example 1
Social Security Administration
Supplemental Security Income
Notice of Overpayment
Date: August 24, 1988
Claim Number: XXX-XX-XXXX
Name
Street Address
City/State/Zip Code
We are writing to you about the SSI recipient's overpayment of $125.00. You asked
that we not make you pay this money back. We decided that you do have to pay back
the overpayment.
THE REASON FOR OUR DECISION
We said that you did not have to pay back the overpayment if you had a good reason
for not reporting the increase in your earnings. Base on the facts you gave us, we
decided not a good reason. This is because we told you that you must report any changes
in your earnings.
DO YOU THINK WE ARE WRONG?
If you think we are wrong, you have the right to appeal. We will correct mistakes.
We will look at any new facts you have.
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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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•
You will have to have a good reason for waiting more than 60 days to ask for an appeal.
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•
To appeal, you must fill out a form call “Request for Reconsideration.” The form number is SSA-561. To get this form, contact, contact one of our offices.
We can help you fill out form.
HOW TO APPEAL
There are three ways to appeal. You can pick the one you want. If you meet with us
in person, it may help us decide your case .
Example 1(cont.)
xxx-xx-xxxx
08/24/88 Page 2
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•
Case Review . You have a right to review the facts in your file. You can give us more facts to
add to your file. Then we will decide your case again. You will not meet with the
person who decides your case.
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•
Informal Conference . You will meet with the person who decides your case. You can tell that person why
you think you are right. You can give us more facts to help prove your are right.
You can bring other people to help explain your case.
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•
Formal Conference . This is a meeting like an information conference. The difference is we can make
people come to help prove you are right. We can make them bring important papers about
your case, even if they do not want to help you. You can question these people at
your meeting.
IF YOU WANT HELP WITH YOUR APPEAL
You may want help from a friend, lawyer or someone else. There are groups that can
find you a lawyer. Some can give you a free lawyer. We can give you the means of these
groups.
HOW TO PAY US BACK
There are two ways you can pay us back.
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•
You can send us a check or money order for the full amount of the overpayment of $125.00.
Make your check or money order out to the Social Security Administration. Be sure
to put the recipient's Social Security on it. Please use the enclosed envelope to
mail the check or money order to us. Also, be sure to enclose the payment stub with
your check or money order.
OR
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•
If you cannot send us the full amount now, send as much as you can. Then contact any
Social office. You can pay the rest of the money you owe by making monthly payments.
If you cannot pay us in full, please contact us by September 26, 1988. You will need
to tell us how you plan to pay us back.
Example 1(cont.)
xxx-xx-xxxx
08/24/88 Page 3
If you do not pay back this money, we must withhold it from any future Social Security
or SSI benefits that you may receive.
IF YOU HAVE ANY QUESTIONS
If you have any questions, you may call, write or visit any Social Security office.
If you call or visit our office, please have this letter with you and ask for a representative.
The telephone number is (111) 111-1111.
Also, if you plan to visit an office, you may call ahead to make a appointment. This
will help us serve you more quickly when you arrive at the office.
Name
District/Branch Manager
Enclosures:
— Detailed Explanation of Overpayment
— Payment Stub
— Refund Envelope
Example 2
Social Security Administration
Supplemental Security Income
Notice of Overpayment
Date: January 12, 1989
Claim Number: XXX-XX-XXXX
Name
Street Address
City/State/Zip
We are writing to let you know that we have paid the SSI recipient $125.00 too much
Supplemental Security Income (SSI) money. The overpayment happened from October 1987
through November 1987.
The SSI recipient is an alien you sponsored to admission to the United States and
agree to support. They were overpaid because you did not report your earnings. Therefore,
you must pay back the overpayment, or we must withhold it from any future Social Security
or SSI benefits that you may receive.
Later in this letter, we will give you a detailed explanation of the overpayment.
You must pay us back unless we are wrong about he overpayment or we decide you should
not have to pay us back. This letter tells you what you can do if you thing we are
wrong about the overpayment, or if you think you should not have to pay us back.
IF YOU THINK YOU SHOULD NOT HAVE TO PAY US BACK
You may not have to pay us back if you had a good reason for not telling us about
your earnings. If you think that you had a good reason, let us know. You will not
have to pay us back while we are deciding your case.
DO YOU THINK WE ARE WRONG?
If you think we are wrong, you have the right to appeal. We will correct mistakes.
We will look at any new facts you have.
-
•
You have 60 days to ask for an appeal.
-
•
The 60 days start the day after you get this letter.
-
•
You will have to have a good reason for waiting more than 60 days to ask for an appeal.
Example 2(cont.)
xxx-xx-xxxx
01/12/89 Page 2
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•
To appeal, you must fill out a form call “Request for Reconsideration.” The form number is SSA-561. To this form, contact one of our offices. We can help
you fill out the form.
HOW TO APPEAL
There are three ways to appeal. You can pick the one you want. If you must with us
in person, it may help us decide your case .
-
•
Case Review . You have a right to review the facts in your file. You can give us more facts to
add to your file. Then we will decide your case again. Yo will not meet with the person
who decides your case.
-
•
Informal Conference . You will meet with the person who decides your case. You can tell that person why
you think you are right. You can give us more facts to help prove your are right.
You can bring other people to help explain your case.
-
•
Formal Conference . This is a meeting like an information conference. The difference is we can make
people come to help prove you are right. We can make them bring important papers about
your case, even if they do not want to help you. You can questions these people at
your meeting.
IF YOU WANT HELP WITH YOUR APPEAL
You may want help from a friend, lawyer or someone else. There are groups that can
find you a lawyer. Some can give you a free lawyer. We can give you the names of these
groups.
HOW TO PAY US BACK
There are two ways you can pay us back.
-
•
You can send us a check or money order for the full amount of the overpayment of $125.00
Make your check or money order out to the Social Security Administration. Be sure
to put the SSI recipient's Social Security number on it. Please use enclosed envelope
to mail the check or money order to us. Also, be sure to enclose the payment stub
with your check or money order.
Example 2(cont.)
xxx-xx-xxxx
01/12/89 Page 3
OR
-
•
If you cannot send us the full amount now, send as much as you can. Then contact any
Social Security office. You can pay the rest of the money you owe by making monthly
payments.
If you cannot pay us in full, please contact us by February 13, 1989. You will need
to tell us how you plan to pay us back.
If you do not pay back this money, we must withhold it from any future Social Security
or SSI benefits that you may receive.
IF YOU HAVE ANY QUESTIONS
If you have any questions, you may call, write or visit any Social Security office.
If you call or visit our office, please have this letter with you and ask for a representative.
The telephone number is (111) 111-1111.
Also, if you plan to visit an office, you may call ahead to make an appointment. This
will help us serve you more quickly when you arrive at the office.
Name
District/Branch Manager
Enclosures:
—Detailed Explanation of Overpayment
—Payment Stub
—Refund Envelope