The Overpayment Information notice has 6 fill-ins. Fill-ins (1) through (3) apply to both the SSA-L8173-U3 and SSA-L8174-U3 . Fill-ins (4) through (6) appear only on the SSA-L8173-U3 and are used to propose check adjustment.

Fill-in (1) is located in the introductory paragraph of the notice as follows:

“We are writing to tell you that we decided not to waive your Supplemental Security Income (SSI) overpayment of    (1)    . This means that you....”

Fill-in (2) is located at the blank area provided at the end of the paragraph under the caption “The Reason For Our Decision” as follows:

“Based on the facts you gave us, we have decided    (2)    .”

Fill-in (3) is a caption and paragraph used only on the representative payee's copy of the notice when the payee questioned representative payee liability (SI 02201.021) at the time the waiver request was filed. Fill-in (3) comes after the explanation for the waiver denial.

Enter the amount of the overpayment subject to recovery in fill-in (1).

Complete fill-in (2) with an explanation of why you denied the waiver request. Keep the explanation as simple as possible without using technical terms.

If appropriate, include fill-in (3) as follows:

Caption: “Special Message For You As The Representative Payee”

Paragraph: “You're responsible for paying us back because you were (overpaid individual's name's)  representative payee when (he/ she)  was overpaid.”