Social Security Administration
Electronic Payment Reminder
Important Information
Program Service Center
Address
City, State, Zip Code
Date: (*F1)
BNC: (*F2)
JANE DOE
123 BALTIMORE ST
BALTIMORE, MD 21201
We are sending you this letter in both a standard print version and (*F1). You will
receive them in separate envelopes.
This statement concerns an overpayment of (*F1) paid to (*F2) (*F3).
The remaining balance in your account is (*F1).
Electronic Payment Options
We noticed that we have still not received your payment. Did you know that you can make
a payment online?
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You can use the Pay.gov portal to make a secure payment at www.pay.gov/public/form/start/834689469
online. Your Remittance ID is (*F1); OR
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You can use your financial institution’s online bill payment option. Search for “Social
Security Administration”, and in the “Account Number” section, enter your Remittance
ID of (*F1).
Suspect Social Security Fraud?
If you suspect Social Security fraud, please visit http://oig.ssa.gov/report or call the Inspector General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).
If You Have Questions
If you have questions about this statement, please call us at (*F1). The office hours
are Monday through Friday, (*F2).
If you call us using a TDD machine, please pause after you type a few words. This
will give us time to transfer your call to the TDD line.
Need more help?
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2.
Call us at 1-800-772-1213, weekdays from 8:00 am to 7:00 pm. If you are deaf or hard of hearing, call TTY 1-800-325-0778. Please mention this letter when you call.
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3.
You may also call your local office at (*F1)
(*F2)
(*F3)
(*F4)
(*F5)
(*F6)
(*F7)
How are we doing? Go to www.ssa.gov/feedback to tell us.
Social Security Administration
Privacy Act Statement
Collection and Use of Personal Information
Section 204 of the Social Security Act, as amended, allows us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part
of the information may prevent us from processing your overpayment.
We will use the information you provide to process your overpayment. We may also share
the information for the following purposes, called routine uses:
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To third party contacts such as privacy collection agencies and credit reporting agencies
under contract with the Social Security Administration (SSA) and other agencies, including
the Veterans Administration, the Armed Forces, the Department of Treasury, and State
motor vehicle agencies, for purposes of their assisting SSA in recovering program
debt; and
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To students, volunteers and other workers, who technically do not have the status
of Federal employees, when they are performing work for SSA as authorized by law,
and they need access to personally identifiable information in SSA records in order
to perform their assigned agency functions.
In addition, we may share this information in accordance with the Privacy Act and
other Federal laws. For example, where authorized, we may use and disclose this information
in computer matching programs, in which our records are compared with other records
to establish or verify a person’s eligibility for Federal benefit programs and for
repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records
Notice (SORN) 60-0094 Recovery of Overpayments, Accounting and Reporting/Debt Management
System (ROAR/DMS), as published in the Federal Register (FR) on August 23, 2005, at
70 FR 49354. Additional information, and a full listing of all of our SORNs, is available
on our website at www.ssa.gov/privacy.