TN 121 (08-25)

NL 00703.200 Request to Payee for Payment of Misused Funds Overpayment

(GN 00604.045)

Document Identifier for Word Processor: E3200

DPS

EXHIBIT LETTER

We are writing to let you know that you must return $(1) of the (2) money we sent you as (3) payee. We have determined that you did not use this money for (4) as you agreed to do. You must pay us back so that we can make sure (5) the money. The following gives you more information about our determination.

How We Reached Our Determination

(6)

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 you owe us. Make your check or money order payable to the Social Security Administration. Be sure to include your (7) on the check or money order. Please use the enclosed envelope to mail your check or money order to us.

• •

  If you cannot send 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.

We will make sure (8) the money you return.

If we do not receive your refund payment within 30 days, we plan to recover the overpayment by withholding 50 percent of your total benefit or $10 (whichever is more) each month beginning with the payment you will receive on or about (9). If your total benefit is less than $10, we will withhold the entire benefit. We will continue withholding until the overpayment has been fully recovered. (OPT014 if T16/concurrent, 10%; RPN056 if full withholding any benefit, court ordered restitution or similar fault; or none if no benefits)

(RPN057 if foreign; or none if domestic)

If You Think You Should Not Have to Pay Us Back

You might not have to pay us back. Sometimes we can waive the collection of an overpayment, which means you will not have to pay us back. For us to waive the collection of the overpayment, two things must be true.

• •

  The misuse overpayment was not your fault.

AND

• •

  Paying us back would mean you cannot pay your bills for food, clothing, housing, medical care, or other necessary expenses, or it would be unfair for some other reason.

If you think these are true about you, contact any Social Security office. You can ask for waiver at any time by filling out the waiver form. The form number is SSA-632-BK. We will not collect the overpayment while we decide if we can waive collection. If you ask for waiver in the next 30 days, we will not withhold benefits until we decide if we can waive collection.

You may need to show us proof of your monthly income, expenses, and assets. Examples are pay stubs, pension records, rent receipts, utility bills, and bank statements. (RPN051 if not receiving benefits and no conviction; RPN052 if organization and no conviction; or none if court conviction)

If You Disagree with Our Determination

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.

• You have 60 days to ask for an appeal. If you ask in the next 30 days, we won't change your check until we decide the case.

• Both the 30-day and the 60-day periods 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.

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

• You must ask for an appeal in writing. The fastest and easiest way to file an appeal is to visit 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 www.ssa.gov/forms to find the form SSA-561. You can also contact us by phone, mail, or come into an office to request the form. If you need help to fill out the form, we can help you by phone or in person. (RPN054 if not receiving benefits or organization)

If You Want Help With Your Appeal

You can have a friend, representative, or someone else help you. There are groups that can help you find a representative or give you free legal services if you qualify. There also are representatives who do not charge unless you win your appeal. Your local Social Security office has a list of groups that can help you with your appeal.

(MIS117)

(REF196)

(SSAS30)

Enclosure(s):

Refund Envelope

Fill-ins:

1. (1) 

   amount of misused funds to be refunded, in the format 365.00

2. (2) 

   Social Security, Supplemental Security Income, Social Security and Supplemental Security Income

3. (3) 

   beneficiary or recipient's full name, possessive case, in the format “John Day's”, or blank if multiple beneficiaries

4. (4) 

   her, him, them, the beneficiaries

5. (5) 

   he gets, she gets, they get

6. (6) 

   narrative discussion of the misuse decision (SSAH16)

7. (7) 

   "Social Security number," or "Employer Identification Number" (if organizational payee)

8. (8) 

   beneficiary name "gets" or "they get"

9. (9) 

   Three months in the future, in the format Month, DD, YYYY